4TH Avenue Dental, PA, Dba Oak Park Dental

Key facts

NPI: 1609298355
Entity type: Organization (NPI type 2)
Primary specialty: General Practice Dentistry 1223G0001X
License: D11935 (MN)
Legal business name: 4TH AVENUE DENTAL, PA, DBA OAK PARK DENTAL
Practice address: 505 Johnson Ave SE
Pine City, MN 55063-2108
Phone: (320) 629-2282
Fax: (320) 629-3357
NPI assigned: Jan 15, 2014
Organization subpart: No

Authorized official

Name: Alicia Ascheman
Title: Supervisor/Owner
Phone: (320) 629-2282

National Provider Directory

Locations

505 Johnson Ave SE
Pine City, MN 55063
Phone (320) 629-2282

Specialties & licenses

Specialty (taxonomy)	Code	License	State	Primary
General Practice Dentistry Group: 193400000X SINGLE SPECIALTY GROUP	1223G0001X	D11935	MN	Yes

Addresses

Primary practice location

505 Johnson Ave SE
Pine City, MN 55063-2108

Mailing address

505 Johnson Ave SE
Pine City, MN 55063-2108
Phone (320) 629-2282

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 15, 2014.

{
    "created_epoch": "1389744000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1389744000000",
    "number": "1609298355",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "505 JOHNSON AVE SE",
            "city": "PINE CITY",
            "state": "MN",
            "postal_code": "550632108",
            "telephone_number": "320-629-2282",
            "fax_number": "320-629-3357"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "505 JOHNSON AVE SE",
            "city": "PINE CITY",
            "state": "MN",
            "postal_code": "550632108",
            "telephone_number": "320-629-2282",
            "fax_number": "320-629-3357"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "4TH AVENUE DENTAL, PA, DBA OAK PARK DENTAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-01-15",
        "last_updated": "2014-01-15",
        "status": "A",
        "authorized_official_last_name": "ASCHEMAN",
        "authorized_official_first_name": "ALICIA",
        "authorized_official_title_or_position": "SUPERVISOR/OWNER",
        "authorized_official_telephone_number": "320-629-2282"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D11935",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Pine City, MN

All providers in Pine City, MN · General Practice Dentistry in Minnesota

Sources for this page

NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jan 15, 2014. Information in NPPES is self-reported and not verified by CMS.
NUCC Health Care Provider Taxonomy: specialty names.
National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.