Provider Demographics
NPI:1508161779
Name:PROFESSIONAL DENTAL ALLIANCE
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:S
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:330-533-3400
Mailing Address - Street 1:3800 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9029
Mailing Address - Country:US
Mailing Address - Phone:330-533-3400
Mailing Address - Fax:330-533-2700
Practice Address - Street 1:12808 DREXMORE RD
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44120-5609
Practice Address - Country:US
Practice Address - Phone:216-921-8888
Practice Address - Fax:330-533-2700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROFESSIONAL DENTAL ALLIANCE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300224691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty