Provider Demographics
NPI:1124457494
Name:PROFESSIONAL DENTAL ALLIANCE OF MICHIGAN, LLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF MICHIGAN, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAMS
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-573-7500
Mailing Address - Street 1:11 S MILL ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3613
Mailing Address - Country:US
Mailing Address - Phone:724-698-2500
Mailing Address - Fax:
Practice Address - Street 1:37595 7 MILE RD
Practice Address - Street 2:STE 450
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1003
Practice Address - Country:US
Practice Address - Phone:734-855-4474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty