=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710131594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THREE RIVERS DENTAL GROUP/GREENTREE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2008
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 950 GREENTREE ROAD SUITE 300
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-921-2545
-----------------------------------------------------
Fax | 412-458-1965
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 950 GREENTREE ROAD SUITE 300
-----------------------------------------------------
City | PITTSBURGH
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 15220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 412-921-2545
-----------------------------------------------------
Fax | 412-458-1965
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | ANA BIANCA RUDOLPH
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 724-961-4363
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | PA21586-L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------