Provider Demographics
NPI:1760473086
Name:PORTNOFF, TRACI A (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRACI
Middle Name:A
Last Name:PORTNOFF
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HUCKLEBERRY RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINTON
Mailing Address - State:MA
Mailing Address - Zip Code:01748-1055
Mailing Address - Country:US
Mailing Address - Phone:508-544-1416
Mailing Address - Fax:
Practice Address - Street 1:65 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-2516
Practice Address - Country:US
Practice Address - Phone:508-366-3623
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19517122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAU80884Medicare UPIN