Provider Demographics
NPI:1639231681
Name:PORTIS, KAREN J (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:J
Last Name:PORTIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KAREN
Other - Middle Name:J
Other - Last Name:MAILO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1395 CURVE CREST BLVD W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-430-0036
Mailing Address - Fax:651-430-0191
Practice Address - Street 1:1395 CURVE CREST BLVD W
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-430-0036
Practice Address - Fax:651-430-0191
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice