Healthcare Provider Details

I. General information

NPI: 1942712153
Provider Name (Legal Business Name): PDA OF MICHIGAN NON-PAR, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: ANNETTE MARLOW
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 724-698-2119