Provider Demographics
NPI:1407493760
Name:PORTAGE FAMILY DENTISTRY PLLC
Entity Type:Organization
Organization Name:PORTAGE FAMILY DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLISON
Authorized Official - Middle Name:T
Authorized Official - Last Name:CRUTCHFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:480-335-5351
Mailing Address - Street 1:5260 SADDLE CLUB DR
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9773
Mailing Address - Country:US
Mailing Address - Phone:480-335-5351
Mailing Address - Fax:
Practice Address - Street 1:200 E CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-5505
Practice Address - Country:US
Practice Address - Phone:269-327-3005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental