Provider Demographics
NPI:1861788960
Name:FIRST AVENUE DENTAL, P.A.
Entity type:Organization
Organization Name:FIRST AVENUE DENTAL, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESICKA
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-225-5154
Mailing Address - Street 1:2306 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-2527
Mailing Address - Country:US
Mailing Address - Phone:620-225-5154
Mailing Address - Fax:620-371-8870
Practice Address - Street 1:2306 1ST AVE
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2527
Practice Address - Country:US
Practice Address - Phone:620-371-6630
Practice Address - Fax:620-371-6631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-27
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200867320AMedicaid
KS201223110AMedicaid