Provider Demographics
NPI:1144045840
Name:AVON DENTAL PLLC
Entity type:Organization
Organization Name:AVON DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLETTE
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:PORTTIIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:952-686-8444
Mailing Address - Street 1:24183 69TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTA
Mailing Address - State:MN
Mailing Address - Zip Code:56301-8402
Mailing Address - Country:US
Mailing Address - Phone:952-686-8444
Mailing Address - Fax:
Practice Address - Street 1:308A BLATTNER DR
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:MN
Practice Address - Zip Code:56310-8674
Practice Address - Country:US
Practice Address - Phone:320-356-7374
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental