Provider Demographics
NPI:1609946482
Name:PORTNOY, P MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:P
Middle Name:MARK
Last Name:PORTNOY
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 1:8240 BEVERLY BLVD
Mailing Address - Street 2:#9
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-4529
Mailing Address - Country:US
Mailing Address - Phone:323-658-6970
Mailing Address - Fax:
Practice Address - Street 1:8240 BEVERLY BLVD
Practice Address - Street 2:#9
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4529
Practice Address - Country:US
Practice Address - Phone:323-658-6970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA273531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27353OtherDENTAL LICENSE
95-3912311OtherTAX ID