Provider Demographics
NPI:1821369455
Name:PDA HOLDCO, LLC
Entity Type:Organization
Organization Name:PDA HOLDCO, LLC
Other - Org Name:MAGIC SMILES DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRISSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-253-6600
Mailing Address - Street 1:1701 E THOMAS RD
Mailing Address - Street 2:SUITE #204
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-7646
Mailing Address - Country:US
Mailing Address - Phone:602-253-6600
Mailing Address - Fax:602-279-0821
Practice Address - Street 1:1457 W SOUTHERN AVE STE 18
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4853
Practice Address - Country:US
Practice Address - Phone:480-610-2300
Practice Address - Fax:480-833-0682
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PDA HOLDINGS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-12
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD5504122300000X
261QD0000X
AZD3044122300000X
AZD04384122300000X
AZD7393122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ670703Medicaid