Provider Demographics
NPI:1154843837
Name:PORTILLO, KAREN MARIE (RDH, MSDH)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:MARIE
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:RDH, MSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3074 ARVILLE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-7490
Mailing Address - Country:US
Mailing Address - Phone:702-889-3763
Mailing Address - Fax:
Practice Address - Street 1:3074 ARVILLE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-7490
Practice Address - Country:US
Practice Address - Phone:702-889-3763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3033124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist