Healthcare Provider Details

I. General information

NPI: 1184449977
Provider Name (Legal Business Name): PROFESSIONAL DENTAL ALLIANCE OF CT - PEDO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1478 POST RD
FAIRFIELD CT
06824-5938
US

IV. Provider business mailing address

125 ENTERPRISE DR
PITTSBURGH PA
15275-1223
US

V. Phone/Fax

Practice location:
  • Phone: 203-307-1550
  • Fax: 203-255-7782
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: ERICA QUINTEROS
Title or Position: CREDENTIALING
Credential:
Phone: 724-901-1964