Healthcare Provider Details

I. General information

NPI: 1861788945
Provider Name (Legal Business Name): PROFESSIONAL DENTAL ALLIANCE SPECIALTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 03/25/2024
Certification Date: 03/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6540 SOUTH AVE
BOARDMAN OH
44512-3651
US

IV. Provider business mailing address

125 ENTERPRISE DR STE 200
PITTSBURGH PA
15275-1223
US

V. Phone/Fax

Practice location:
  • Phone: 330-721-0606
  • Fax:
Mailing address:
  • Phone: 724-698-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateOH
# 6
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number StateOH
# 9
Primary TaxonomyN
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number StateOH
# 10
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateOH

VIII. Authorized Official

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