Provider Demographics
NPI:1912920059
Name:MADISON AVENUE FAMILY DENTAL CENTER, LTD
Entity Type:Organization
Organization Name:MADISON AVENUE FAMILY DENTAL CENTER, LTD
Other - Org Name:ADVANCED DENTAL SOLUTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:TORBENSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-345-1284
Mailing Address - Street 1:608 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6112
Mailing Address - Country:US
Mailing Address - Phone:507-345-1284
Mailing Address - Fax:507-345-5723
Practice Address - Street 1:608 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6112
Practice Address - Country:US
Practice Address - Phone:507-345-1284
Practice Address - Fax:507-345-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8804122300000X
MND11277122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MND11277OtherNEUMANN, LICENSE #
MN5723159OtherMN TAX ID
MN8804OtherKEVIN TORBENSON, LICENSE
MN3273752000OtherUNEMPLOYMENT TAX ID
MN3273752000OtherUNEMPLOYMENT TAX ID
MNAT8688775OtherDEA #, KEVIN TORBENSON
MND11277OtherNEUMANN, LICENSE #
MN8804OtherKEVIN TORBENSON, LICENSE