Provider Demographics
NPI:1184366866
Name:PROFESSIONAL DENTAL ASSOCIATES LLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:410-638-0858
Mailing Address - Street 1:615 W MACPHAIL RD STE 208
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4469
Mailing Address - Country:US
Mailing Address - Phone:410-638-0858
Mailing Address - Fax:410-638-0858
Practice Address - Street 1:615 W MACPHAIL RD STE 208
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4469
Practice Address - Country:US
Practice Address - Phone:410-638-0858
Practice Address - Fax:410-638-0057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-12
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty