Provider Demographics
NPI:1518583608
Name:PORTAGE DENTAL GROUP, JEFFREY S. ROSENTHAL D.D.S., INC.
Entity Type:Organization
Organization Name:PORTAGE DENTAL GROUP, JEFFREY S. ROSENTHAL D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROSENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:216-905-8454
Mailing Address - Street 1:644 S CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-3035
Mailing Address - Country:US
Mailing Address - Phone:330-297-7009
Mailing Address - Fax:
Practice Address - Street 1:644 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-3035
Practice Address - Country:US
Practice Address - Phone:330-297-7009
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-24
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental