=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144914052
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER DENTAL ALLIANCE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2023
-----------------------------------------------------
Last Update Date | 11/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1040 TOWNE SQUARE DR. SUITE 2
-----------------------------------------------------
City | GREENSBURG
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15601-5769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-836-3368
-----------------------------------------------------
Fax | 724-836-1209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 234 SOUTH MAIN STREET
-----------------------------------------------------
City | HOMER CITY
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15748-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-349-3368
-----------------------------------------------------
Fax | 724-717-6141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOSHUA A PARRY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 724-836-3368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------