Provider Demographics
NPI:1316093024
Name:PORTAGE DENTAL CENTER
Entity type:Organization
Organization Name:PORTAGE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR MGR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-297-7009
Mailing Address - Street 1:250 S CHESTNUT ST STE 30
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3031
Mailing Address - Country:US
Mailing Address - Phone:330-297-7009
Mailing Address - Fax:330-297-0901
Practice Address - Street 1:250 S CHESTNUT ST STE 30
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3031
Practice Address - Country:US
Practice Address - Phone:330-297-7009
Practice Address - Fax:330-297-0901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0468597Medicaid