Provider Demographics
NPI:1770503450
Name:PORTENOY, BRADLEY S (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:S
Last Name:PORTENOY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 MERRICK RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-5359
Mailing Address - Country:US
Mailing Address - Phone:516-764-4386
Mailing Address - Fax:516-764-4389
Practice Address - Street 1:371 MERRICK RD
Practice Address - Street 2:SUITE 304
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5359
Practice Address - Country:US
Practice Address - Phone:516-764-4386
Practice Address - Fax:516-764-4389
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039517-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice