Provider Demographics
NPI:1023707387
Name:PORTELLES, TONY
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:PORTELLES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2759 W 55TH ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-2251
Mailing Address - Country:US
Mailing Address - Phone:773-776-5277
Mailing Address - Fax:
Practice Address - Street 1:9730 HAZEL FERN CT
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77379-5395
Practice Address - Country:US
Practice Address - Phone:281-783-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX404121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice