Provider Demographics
NPI:1073737649
Name:PORTNOY, MELVIN
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:
Last Name:PORTNOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SUFFOLK SQ
Mailing Address - Street 2:STE 200
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749
Mailing Address - Country:US
Mailing Address - Phone:631-348-7777
Mailing Address - Fax:631-348-7794
Practice Address - Street 1:1 SUFFOLK SQ
Practice Address - Street 2:STE 200
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749
Practice Address - Country:US
Practice Address - Phone:631-348-7777
Practice Address - Fax:631-348-7794
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY260571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00292246Medicaid