Professional Dental Alliance Specialty, LLC

Primary specialty

DentistTaxonomy code 122300000X

Legal business name

PROFESSIONAL DENTAL ALLIANCE SPECIALTY, LLC

Practice address

6540 South Ave
Boardman, OH 44512-3651

Phone

(330) 721-0606

NPI assigned

Jun 27, 2011

Last updated

Mar 25, 2024By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Erica Quinteros

Title

Credentialing

Phone

(724) 901-1964

Specialties & licenses 10

Addresses

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

{
    "created_epoch": "1309132800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1711324800000",
    "number": "1861788945",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "125 ENTERPRISE DR STE 200",
            "city": "PITTSBURGH",
            "state": "PA",
            "postal_code": "152751223",
            "telephone_number": "724-698-2500"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6540 SOUTH AVE",
            "city": "BOARDMAN",
            "state": "OH",
            "postal_code": "445123651",
            "telephone_number": "330-721-0606"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROFESSIONAL DENTAL ALLIANCE SPECIALTY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-06-27",
        "last_updated": "2024-03-25",
        "certification_date": "2024-03-25",
        "status": "A",
        "authorized_official_last_name": "QUINTEROS",
        "authorized_official_first_name": "ERICA",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "724-901-1964"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "OH",
            "license": null,
            "primary": true
        },
        {
            "code": "1223E0200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Endodontics",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, General Practice",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "1223P0106X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Pathology",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "1223P0221X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Periodontics",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "1223P0700X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Prosthodontics",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "1223X0008X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Dentist, Oral and Maxillofacial Radiology",
            "state": "OH",
            "license": null,
            "primary": false
        },
        {
            "code": "122400000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Denturist",
            "state": "OH",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 25, 2024; 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.