Healthcare Provider Details

I. General information

NPI: 1114455441
Provider Name (Legal Business Name): PDA ORTHO SPECIALTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13022 PEARL RD STE 23
STRONGSVILLE OH
44136-3442
US

IV. Provider business mailing address

11 S MILL ST STE 200
NEW CASTLE PA
16101-3680
US

V. Phone/Fax

Practice location:
  • Phone: 440-238-0770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ANDREW MATTA
Title or Position: OWNER
Credential:
Phone: 724-698-2500