Provider Demographics
NPI:1184753691
Name:PORTENGA, ROBERT S (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:S
Last Name:PORTENGA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:432 MUNSON PL
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3098
Mailing Address - Country:US
Mailing Address - Phone:231-947-3570
Mailing Address - Fax:231-947-5160
Practice Address - Street 1:432 MUNSON PL
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3098
Practice Address - Country:US
Practice Address - Phone:231-947-3570
Practice Address - Fax:231-947-5160
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010097811223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics