Provider Demographics
NPI:1356882989
Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:MATTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-698-2500
Mailing Address - Street 1:11 S MILL ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3613
Mailing Address - Country:US
Mailing Address - Phone:724-698-2500
Mailing Address - Fax:724-652-4619
Practice Address - Street 1:1730 SCHROCK RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43229-1575
Practice Address - Country:US
Practice Address - Phone:614-890-3590
Practice Address - Fax:614-890-3597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty