Provider Demographics
NPI:1477883429
Name:UPMC PRESBYTERIAN SHADYSIDE
Entity Type:Organization
Organization Name:UPMC PRESBYTERIAN SHADYSIDE
Other - Org Name:BRADDOCK DENTAL CENTER OF UPMC PRESBYTERIAN SHADYSIDE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-647-7713
Mailing Address - Street 1:818 BRADDOCK AVE
Mailing Address - Street 2:
Mailing Address - City:BRADDOCK
Mailing Address - State:PA
Mailing Address - Zip Code:15104-1715
Mailing Address - Country:US
Mailing Address - Phone:412-636-5187
Mailing Address - Fax:412-636-5248
Practice Address - Street 1:818 BRADDOCK AVE
Practice Address - Street 2:
Practice Address - City:BRADDOCK
Practice Address - State:PA
Practice Address - Zip Code:15104-1715
Practice Address - Country:US
Practice Address - Phone:412-636-5187
Practice Address - Fax:412-636-5248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037519261QD0000X
PADS027386L261QD0000X
PADS030969L261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007360690004Medicaid