Provider Demographics
NPI:1790179992
Name:PROFESSIONAL DENTAL ALLIANCE
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE
Other - Org Name:PROFESSIONAL DENTAL ALLIANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:724-674-2965
Mailing Address - Street 1:11 S MILL ST
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3613
Mailing Address - Country:US
Mailing Address - Phone:724-698-2500
Mailing Address - Fax:
Practice Address - Street 1:11201 SHAKER BLVD
Practice Address - Street 2:136
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44104-3869
Practice Address - Country:US
Practice Address - Phone:216-368-7238
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023665122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH30023665OtherLICENSE NUMBER