MEDICARE: PROFESSIONAL DENTAL ALLIANCE OF KETTERING, LLC

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1558915322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL ALLIANCE OF KETTERING, LLC

Provider Business Mailing Address
First Line	:	11 S MILL ST STE 200
Second Line	:
City	:	NEW CASTLE
State	:	PA
Zip	:	16101-3680
Country	:	US
Telephone Number	:	757-576-5479
Fax Number	:

Provider Business Practice Location Address
First Line	:	4055 FAR HILLS AVE
Second Line	:
City	:	KETTERING
State	:	OH
Zip	:	45429-2440
Country	:	US
Telephone Number	:	937-299-3691
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	LAUREN HOWARD
Credential	:
Telephone Number	:	757-576-5479

Provider Enumeration Date	:	07/30/2019
Last Update Date	:	07/30/2019

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