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General NPI Number Information
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NPI Number | 1679093330
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL DENTAL ALLIANCE OF DEFIANCE, LLC
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Dates
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Enumeration Date | 06/23/2017
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Last Update Date | 06/23/2017
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Provider Practice Location Address
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Address Line | 100 STADIUM DR STE A
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City | DEFIANCE
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State | OH
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Zip | 43512-4615
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Country | US
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Telephone | 419-784-0775
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Fax |
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Provider Business Mailing Address
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Address Line | 11 S MILL ST STE 200
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City | NEW CASTLE
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State | PA
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Zip | 16101-3680
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Country | US
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Telephone | 724-698-2500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | ANDREW MATTA
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Credential |
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Telephone | 724-698-2500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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