Provider Demographics
NPI:1336831445
Name:FIRST AVENUE DENTAL PLLC
Entity Type:Organization
Organization Name:FIRST AVENUE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACHARY
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:320-241-6927
Mailing Address - Street 1:720 ROBERTS RD APT 310
Mailing Address - Street 2:
Mailing Address - City:SARTELL
Mailing Address - State:MN
Mailing Address - Zip Code:56377-3403
Mailing Address - Country:US
Mailing Address - Phone:320-241-6927
Mailing Address - Fax:
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:320-241-6927
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-25
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty