MEDICARE: PROFESSIONAL DENTAL ALLIANCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	30022469	OH

General Provider Information

NPI Number	:	1548565849
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL ALLIANCE

Provider Business Mailing Address
First Line	:	3800 BOARDMAN CANFIELD RD
Second Line	:
City	:	CANFIELD
State	:	OH
Zip	:	44406-9029
Country	:	US
Telephone Number	:	330-533-3400
Fax Number	:	330-533-2700

Provider Business Practice Location Address
First Line	:	101 S MAIN ST
Second Line	:
City	:	POLAND
State	:	OH
Zip	:	44514-2062
Country	:	US
Telephone Number	:	330-757-0880
Fax Number	:	330-533-3400

Authorized Official
Title or Position	:	MEMBER
Name	:	ANDREW S MATTA
Credential	:	DMD
Telephone Number	:	330-533-3400

Provider Enumeration Date	:	01/18/2011
Last Update Date	:	01/18/2011

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