Provider Demographics
NPI:1366817827
Name:PORTAGE PEDIATRIC DENTISTRY PLC
Entity Type:Organization
Organization Name:PORTAGE PEDIATRIC DENTISTRY PLC
Other - Org Name:PORTAGE PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JODY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WRATHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:269-323-8016
Mailing Address - Street 1:6121 S WESTNEDGE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-2882
Mailing Address - Country:US
Mailing Address - Phone:269-323-8016
Mailing Address - Fax:269-323-8524
Practice Address - Street 1:6121 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-2882
Practice Address - Country:US
Practice Address - Phone:269-323-8016
Practice Address - Fax:269-323-8524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010203391223P0221X
MI29010098771223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty