Healthcare Provider Details

I. General information

NPI: 1720695703
Provider Name (Legal Business Name): PROFESSIONAL DENTAL ALLIANCE OF MARYLAND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 RIVER AVE STE B
CUMBERLAND MD
21502-4629
US

IV. Provider business mailing address

11 S MILL ST
NEW CASTLE PA
16101-3680
US

V. Phone/Fax

Practice location:
  • Phone: 240-362-7017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: LAUREN HOWARD
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 757-576-5479