Provider Demographics
NPI:1295486512
Name:PORTAGE NORTHERN DENTAL
Entity type:Organization
Organization Name:PORTAGE NORTHERN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEISE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-246-2204
Mailing Address - Street 1:1220 W MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-1206
Mailing Address - Country:US
Mailing Address - Phone:269-382-5040
Mailing Address - Fax:
Practice Address - Street 1:1220 W MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-1206
Practice Address - Country:US
Practice Address - Phone:269-382-5040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental