1952841330 NPI number — PROFESSIONAL DENTAL ALLIANCE, LLC

Table of content: CARLI ROSE HIMELMAN ARNP (NPI 1093169930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952841330 NPI number — PROFESSIONAL DENTAL ALLIANCE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL DENTAL ALLIANCE, 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:
1952841330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2017
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
Provider Second Line Business Mailing Address:
SUITE 200
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:
724-698-2500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25680 DIXIE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PERRYSBURG
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43551-2019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
567-336-4360
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/03/2017

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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