Healthcare Provider Details

I. General information

NPI: 1891579959
Provider Name (Legal Business Name): PROFESSIONAL DENTAL ALLIANCE OF FL - OON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2350 S HIGHWAY 29
CANTONMENT FL
32533-8508
US

IV. Provider business mailing address

125 ENTERPRISE DR STE 200
PITTSBURGH PA
15275-1223
US

V. Phone/Fax

Practice location:
  • Phone: 850-968-2106
  • Fax:
Mailing address:
  • Phone: 249-011-9647
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

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