Provider Demographics
NPI:1053136846
Name:PROFESSIONAL DENTAL ALLIANCE OF CT - ORTHO, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF CT - ORTHO, 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
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:
Mailing Address - Fax:
Practice Address - Street 1:1476 POST RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5937
Practice Address - Country:US
Practice Address - Phone:203-292-9596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty