Provider Demographics
NPI:1457579773
Name:UPMC BRADDOCK DENTAL CENTER
Entity Type:Organization
Organization Name:UPMC BRADDOCK DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:SEVCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:412-636-5100
Mailing Address - Street 1:450 HOLLAND AVE.
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BRADDOCK
Mailing Address - State:PA
Mailing Address - Zip Code:15104-1536
Mailing Address - Country:US
Mailing Address - Phone:412-636-5187
Mailing Address - Fax:412-636-5248
Practice Address - Street 1:450 HOLLAND AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:BRADDOCK
Practice Address - State:PA
Practice Address - Zip Code:15104-1536
Practice Address - Country:US
Practice Address - Phone:412-636-5187
Practice Address - Fax:412-636-5248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101566-1Medicaid
PA1411127OtherUNITED CONCORDIA
PA1007360690010Medicaid