Provider Demographics
NPI:1831467265
Name:PORTILLA DENTAL GROUP
Entity Type:Organization
Organization Name:PORTILLA DENTAL GROUP
Other - Org Name:A DENTAL SPOT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-738-8300
Mailing Address - Street 1:200 N ASH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92027-3024
Mailing Address - Country:US
Mailing Address - Phone:760-738-8300
Mailing Address - Fax:760-738-9400
Practice Address - Street 1:200 N ASH ST STE 200
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92027-3024
Practice Address - Country:US
Practice Address - Phone:760-738-8300
Practice Address - Fax:760-738-9400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA519891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty