Provider Demographics
NPI:1750948907
Name:PROFESSIONAL DENTAL ALLIANCE OF PRT ST LUCIE PRMA VSTA, PLLC
Entity type:Organization
Organization Name:PROFESSIONAL DENTAL ALLIANCE OF PRT ST LUCIE PRMA VSTA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-698-2997
Mailing Address - Street 1:11 S MILL ST STE 200
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16101-3680
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:499 NW PRIMA VISTA BLVD UNIT 107
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8786
Practice Address - Country:US
Practice Address - Phone:772-336-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty