Provider Demographics
NPI:1801926696
Name:PORTNOY, RAYNA F (DMD)
Entity type:Individual
Prefix:
First Name:RAYNA
Middle Name:F
Last Name:PORTNOY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:RAYNA
Other - Middle Name:FATIMA
Other - Last Name:PORTNOY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD PC
Mailing Address - Street 1:118 35 QUEENS BLVD
Mailing Address - Street 2:LOWER LOBBY
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-544-8686
Mailing Address - Fax:718-793-4366
Practice Address - Street 1:118 35 QUEENS BLVD
Practice Address - Street 2:LOWER LOBBY
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375
Practice Address - Country:US
Practice Address - Phone:718-544-8686
Practice Address - Fax:718-793-4366
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04448311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01426599Medicaid