Provider Demographics
NPI:1689034365
Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Other - Org Name:GROVE CITY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:WISE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-808-1000
Mailing Address - Street 1:4079 GANTZ RD
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-4912
Mailing Address - Country:US
Mailing Address - Phone:614-808-1000
Mailing Address - Fax:614-801-0003
Practice Address - Street 1:11 S MILL ST
Practice Address - Street 2:200
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16101-3613
Practice Address - Country:US
Practice Address - Phone:724-698-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.022975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty