Provider Demographics
NPI:1205997152
Name:FIRST AVENUE DENTAL, PA
Entity type:Organization
Organization Name:FIRST AVENUE DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZETTE
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-632-8113
Mailing Address - Street 1:74 1ST AVE SE
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-3042
Mailing Address - Country:US
Mailing Address - Phone:320-632-8113
Mailing Address - Fax:320-632-5584
Practice Address - Street 1:74 1ST AVE SE
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-3042
Practice Address - Country:US
Practice Address - Phone:320-632-8113
Practice Address - Fax:320-632-5584
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN115991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty