Healthcare Provider Details

I. General information

NPI: 1952185811
Provider Name (Legal Business Name): MNM DENTAL SHADYSIDE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5830 ELLSWORTH AVE STE 304
PITTSBURGH PA
15232-1778
US

IV. Provider business mailing address

5830 ELLSWORTH AVE STE 304
PITTSBURGH PA
15232-1778
US

V. Phone/Fax

Practice location:
  • Phone: 412-730-2560
  • Fax: 412-730-2562
Mailing address:
  • Phone: 412-730-2560
  • Fax: 412-730-2562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: NATALIE BULLOCK
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 412-281-9411