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General NPI Number Information
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NPI Number | 1174018303
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Entity Type | Organization
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Legal Business Name | 412 DENTAL
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Dates
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Enumeration Date | 06/29/2018
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Last Update Date | 06/29/2018
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Provider Practice Location Address
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Address Line | 2526 MONROEVILLE BLVD STE 209
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City | MONROEVILLE
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State | PA
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Zip | 15146-2358
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Country | US
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Telephone | 412-372-2451
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Fax |
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Provider Business Mailing Address
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Address Line | 219 E END AVE # 1
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City | PITTSBURGH
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State | PA
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Zip | 15221-2727
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Country | US
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Telephone | 814-525-8129
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | ELIJAH ED
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Credential |
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Telephone | 412-372-4214
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | DS040035
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License Number State | PA
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