Provider Demographics
NPI:1922531169
Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Entity Type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Other - Org Name:REFRESH DENTAL BALDWIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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
Mailing Address - Street 2:SUITE 200
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 1:4730 CLAIRTON BLVD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15236-2159
Practice Address - Country:US
Practice Address - Phone:412-882-2075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty