MEDICARE: PROFESSIONAL DENTAL ALLIANCE OF BEACHSIDE, PLLC

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	122300000X	Dentist

General Provider Information

NPI Number	:	1669951489
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL ALLIANCE OF BEACHSIDE, PLLC

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	:	724-698-2500
Fax Number	:

Provider Business Practice Location Address
First Line	:	660 E EAU GALLIE BLVD STE 1
Second Line	:
City	:	INDIAN HARBOUR BEACH
State	:	FL
Zip	:	32937-4252
Country	:	US
Telephone Number	:	321-777-7474
Fax Number	:	321-777-7558

Authorized Official
Title or Position	:	CREDENTIALING SUPERVISOR
Name	:	ANNETTE MARLOW
Credential	:
Telephone Number	:	724-698-2119

Provider Enumeration Date	:	08/13/2018
Last Update Date	:	08/13/2018

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