Provider Demographics
NPI:1447621669
Name:WESTERN PENNSYLVANIA DENTAL GROUP
Entity type:Organization
Organization Name:WESTERN PENNSYLVANIA DENTAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:9170 COVENANT AVE BLDG A-2
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237-5961
Mailing Address - Country:US
Mailing Address - Phone:412-548-0184
Mailing Address - Fax:
Practice Address - Street 1:9170 COVENANT AVE BLDG A-2
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5961
Practice Address - Country:US
Practice Address - Phone:412-548-0184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN PENNSYLVANIA DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-14
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X
PADS029676261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty