Provider Demographics
NPI:1508358425
Name:PROFESSIONAL DENTAL ALLIANCE SPECIALTY 2
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE SPECIALTY 2
Other - Org Name:MERIDIAN DENTAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:ANTONINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-765-5019
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:844-399-0385
Practice Address - Street 1:204 MARY HIGGINSON LANE
Practice Address - Street 2:STE. 100
Practice Address - City:UNIONTOWN
Practice Address - State:PA
Practice Address - Zip Code:15401
Practice Address - Country:US
Practice Address - Phone:724-438-0600
Practice Address - Fax:724-438-0601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-06
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty