Provider Demographics
NPI:1740584226
Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KURTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-698-2946
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:
Practice Address - Street 1:7043 PEARL RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44130-4973
Practice Address - Country:US
Practice Address - Phone:330-533-3400
Practice Address - Fax:330-533-2700
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-27
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30022469122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty