Provider Demographics
NPI:1447962055
Name:PROFESSIONAL DENTAL ALLIANCE OF MI - LMTD, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF MI - LMTD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINTEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-901-1964
Mailing Address - Street 1:125 ENTERPRISE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15275-1223
Mailing Address - Country:US
Mailing Address - Phone:726-901-1964
Mailing Address - Fax:
Practice Address - Street 1:27891 23 MILE RD.
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48051
Practice Address - Country:US
Practice Address - Phone:856-840-8050
Practice Address - Fax:586-690-4470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty