Provider Demographics
NPI:1679093330
Name:PROFESSIONAL DENTAL ALLIANCE OF DEFIANCE, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF DEFIANCE, LLC
Other - Org Name:WHITTAKER DENTAL CARE DEFIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-698-2500
Mailing Address - Street 1:11 S MILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3680
Mailing Address - Country:US
Mailing Address - Phone:724-698-2500
Mailing Address - Fax:
Practice Address - Street 1:100 STADIUM DR STE A
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-4615
Practice Address - Country:US
Practice Address - Phone:419-784-0775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:P O BOX 713770, CINCINNATI, OH 45271
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty