Healthcare Provider Details

I. General information

NPI: 1427587047
Provider Name (Legal Business Name): THREE RIVERS DENTAL GROUP/UPPER ST. CLAIR/LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2017
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86 FORT COUCH RD
PITTSBURGH PA
15241-1020
US

IV. Provider business mailing address

86 FORT COUCH RD
PITTSBURGH PA
15241-1020
US

V. Phone/Fax

Practice location:
  • Phone: 412-833-9540
  • Fax: 412-833-4525
Mailing address:
  • Phone: 412-833-9540
  • Fax: 412-833-9546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDS017612L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS021586L
License Number StatePA

VIII. Authorized Official

Name: MS. LORI A MILLIRON
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 724-978-1010