Provider Demographics
NPI:1740899541
Name:PROFESSIONAL DENTAL ALLIANCE OF BURTON, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF BURTON, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-698-2135
Mailing Address - Street 1:11 S MILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3680
Mailing Address - Country:US
Mailing Address - Phone:724-698-2500
Mailing Address - Fax:844-399-0385
Practice Address - Street 1:2414 S CENTER RD STE 1
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48519-1152
Practice Address - Country:US
Practice Address - Phone:810-744-3388
Practice Address - Fax:810-744-4080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-28
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty