NPIMap

Organization Active NPI

Professional Dental Alliance

  • Dentist
  • Cleveland, OH
National Provider Identifier
1790179992
Registry record updated Mar 25, 2015
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
30-023665 Issued in OH
Legal business name
PROFESSIONAL DENTAL ALLIANCE
Practice address
11201 Shaker Blvd
136
Cleveland, OH 44104-3869
Phone
(216) 368-7238
NPI assigned
Mar 25, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 25, 2015

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Andrew Matta, D.D.S.
Title
Chief Medical Officer
Phone
(724) 674-2965

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
DentistGroup: 193400000X SINGLE SPECIALTY GROUP 122300000X 30-023665 OH Primary

Addresses

Primary practice location

11201 Shaker Blvd
136
Cleveland, OH 44104-3869

Mailing address

11 S Mill St
New Castle, PA 16101-3613
Phone (724) 698-2500

Other identifiers 1

IdentifierTypeStateIssuer
30023665OtherOHLICENSE NUMBER

Other names 1

  • Professional Dental Alliance Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Professional Dental Alliance LLC21 organizations share this tax ID, including this one

Other organizations with this tax ID 20

Organizations that report the same tax identification number in the National Provider Directory.

View all 20

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1427241600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1427241600000",
    "number": "1790179992",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11 S MILL ST",
            "city": "NEW CASTLE",
            "state": "PA",
            "postal_code": "161013613",
            "telephone_number": "724-698-2500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11201 SHAKER BLVD",
            "address_2": "136",
            "city": "CLEVELAND",
            "state": "OH",
            "postal_code": "441043869",
            "telephone_number": "216-368-7238"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL DENTAL ALLIANCE",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-03-25",
        "last_updated": "2015-03-25",
        "status": "A",
        "authorized_official_last_name": "MATTA",
        "authorized_official_first_name": "ANDREW",
        "authorized_official_title_or_position": "CHIEF MEDICAL OFFICER",
        "authorized_official_telephone_number": "724-674-2965",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.D.S."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist",
            "state": "OH",
            "license": "30-023665",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE NUMBER",
            "identifier": "30023665",
            "state": "OH"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Professional Dental Alliance",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Cleveland, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.