Provider Demographics
NPI:1942855176
Name:PDA ORTHODONTICS, LLC
Entity Type:Organization
Organization Name:PDA ORTHODONTICS, LLC
Other - Org Name:SAMUELSON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:SAMUELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:205-910-0143
Mailing Address - Street 1:5564 GROVE BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:HOOVER
Mailing Address - State:AL
Mailing Address - Zip Code:35226-4601
Mailing Address - Country:US
Mailing Address - Phone:205-988-9678
Mailing Address - Fax:205-988-9065
Practice Address - Street 1:5564 GROVE BLVD STE A
Practice Address - Street 2:
Practice Address - City:HOOVER
Practice Address - State:AL
Practice Address - Zip Code:35226-4601
Practice Address - Country:US
Practice Address - Phone:205-988-9678
Practice Address - Fax:205-988-9065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-05
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty