Provider Demographics
NPI:1003020280
Name:A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:PORTALUPI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:530-662-9191
Mailing Address - Street 1:1204 COTTONWOOD ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4362
Mailing Address - Country:US
Mailing Address - Phone:530-662-9191
Mailing Address - Fax:530-662-3568
Practice Address - Street 1:1204 COTTONWOOD ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4362
Practice Address - Country:US
Practice Address - Phone:530-662-9191
Practice Address - Fax:530-662-3568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS250661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty