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General NPI Number Information
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NPI Number | 1710458799
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Entity Type | Organization
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Legal Business Name | PROFESSIONAL DENTAL ALLIANCE OF WOODHAVEN, LLC
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Dates
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Enumeration Date | 12/17/2018
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Last Update Date | 12/17/2018
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Provider Practice Location Address
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Address Line | 22319 KING RD
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City | WOODHAVEN
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State | MI
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Zip | 48183-1075
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Country | US
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Telephone | 734-676-7122
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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 | 844-399-0385
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | LAUREN HOWARD
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Credential | MA
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Telephone | 724-698-2029
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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