MEDICARE: PROFESSIONAL DENTAL ALLIANCE OF LILBURN, 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1710544960
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL DENTAL ALLIANCE OF LILBURN, 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	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3970 FIVE FORKS TRICKUM RD SW STE B
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-2339
Country	:	US
Telephone Number	:	770-921-8442
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	JESSICA BARRETTE
Credential	:
Telephone Number	:	724-698-2997

Provider Enumeration Date	:	05/23/2019
Last Update Date	:	05/23/2019

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