Provider Demographics
NPI:1356815401
Name:PROFESSONAL DENTAL ALLIANCE OF WORTHINGTON, LLC
Entity Type:Organization
Organization Name:PROFESSONAL DENTAL ALLIANCE OF WORTHINGTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ENROLLMENT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-901-1964
Mailing Address - Street 1:125 ENTERPRISE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15275-1223
Mailing Address - Country:US
Mailing Address - Phone:724-698-2500
Mailing Address - Fax:
Practice Address - Street 1:150 E WILSON BRIDGE RD STE 150
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085-2394
Practice Address - Country:US
Practice Address - Phone:614-888-0377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty