Healthcare Provider Details

I. General information

NPI: 1083919252
Provider Name (Legal Business Name): PROFESSIONAL DENTAL ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2011
Last Update Date: 01/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 DEBARTOLO PL
BOARDMAN OH
44512-7014
US

IV. Provider business mailing address

3800 BOARDMAN CANFIELD RD
CANFIELD OH
44406-9029
US

V. Phone/Fax

Practice location:
  • Phone: 330-758-2348
  • Fax: 330-533-2700
Mailing address:
  • Phone: 330-533-3400
  • Fax: 330-533-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30022469
License Number StateOH

VIII. Authorized Official

Name: ANDREW S MATTA
Title or Position: MEMBER
Credential: DMD
Phone: 330-533-3400