Provider Demographics
NPI:1477906840
Name:PORTEOUS, LANCE ERIC (DMD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:ERIC
Last Name:PORTEOUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3840 BLACKHAWK RD
Mailing Address - Street 2:#110
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3840 BLACKHAWK RD
Practice Address - Street 2:#110
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4900
Practice Address - Country:US
Practice Address - Phone:925-736-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1004081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice