Healthcare Provider Details

I. General information

NPI: 1588950661
Provider Name (Legal Business Name): PDA ORTHO SPECIALTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 04/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 S MILL ST SUITE 200
NEW CASTLE PA
16101-3613
US

IV. Provider business mailing address

11 S MILL ST SUITE 200
NEW CASTLE PA
16101-3613
US

V. Phone/Fax

Practice location:
  • Phone: 330-533-3400
  • 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 Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateOH

VIII. Authorized Official

Name: DR. ANDREW MATTA
Title or Position: CEO
Credential:
Phone: 330-533-3400