Healthcare Provider Details

I. General information

NPI: 1740584226
Provider Name (Legal Business Name): PROFESSIONAL DENTAL ALLIANCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2010
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7043 PEARL RD
MIDDLEBURG HEIGHTS OH
44130-4973
US

IV. Provider business mailing address

125 ENTERPRISE DR STE 200
PITTSBURGH PA
15275-1223
US

V. Phone/Fax

Practice location:
  • Phone: 330-533-3400
  • Fax: 330-533-2700
Mailing address:
  • Phone: 724-698-2500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30022469
License Number StateOH

VIII. Authorized Official

Name: AMANDA L KURTZ
Title or Position: CREDENTIALING
Credential:
Phone: 724-698-2946