1346796869 NPI number — PROFESSIONAL DENTAL ALLIANCE SPECIALTY, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346796869 NPI number — PROFESSIONAL DENTAL ALLIANCE SPECIALTY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL DENTAL ALLIANCE SPECIALTY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346796869
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 S MILL ST STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW CASTLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16101-3613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-698-2132
Provider Business Mailing Address Fax Number:
724-652-4619

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7131 SPRING MEADOWS DR W
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43528-7939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-865-7433
Provider Business Practice Location Address Fax Number:
419-865-7680
Provider Enumeration Date:
08/26/2016

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
CRED SPECIALIST
Authorized Official Telephone Number:
724-698-2132

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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