Provider Demographics
NPI:1457957185
Name:PORTILLA DENTAL GROUP CORP
Entity type:Organization
Organization Name:PORTILLA DENTAL GROUP CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:IGNACIO
Authorized Official - Last Name:PORTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-738-8300
Mailing Address - Street 1:200 N ASH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92027-3024
Mailing Address - Country:US
Mailing Address - Phone:760-738-8300
Mailing Address - Fax:760-738-9400
Practice Address - Street 1:200 N ASH ST STE 200
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-3024
Practice Address - Country:US
Practice Address - Phone:760-738-8300
Practice Address - Fax:760-738-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-08
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental