Provider Demographics
NPI:1619128857
Name:SOUTH SIDE DENTAL PAVILION
Entity Type:Organization
Organization Name:SOUTH SIDE DENTAL PAVILION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICARLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-431-6631
Mailing Address - Street 1:1408 EAST CARSON STREET
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15203
Mailing Address - Country:US
Mailing Address - Phone:412-431-6631
Mailing Address - Fax:412-431-6297
Practice Address - Street 1:1408 EAST CARSON STREET
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15203
Practice Address - Country:US
Practice Address - Phone:412-431-6631
Practice Address - Fax:412-431-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO18546L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty