Provider Demographics
NPI:1770062465
Name:PROFESSIONAL DENTAL ALLIANCE OF PALM BAY, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF PALM BAY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-725-5512
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:724-698-2132
Mailing Address - Fax:
Practice Address - Street 1:1764 PALM BAY RD NE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-2904
Practice Address - Country:US
Practice Address - Phone:321-725-5512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-13
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty