Healthcare Provider Details

I. General information

NPI: 1902909054
Provider Name (Legal Business Name): RAMON PORTALES JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 S CLOVIS AVE SUITE 107
FRESNO CA
93727-4284
US

IV. Provider business mailing address

7467 N CEDAR AVE PMB #9
FRESNO CA
93720-3637
US

V. Phone/Fax

Practice location:
  • Phone: 559-255-3333
  • Fax: 559-255-7271
Mailing address:
  • Phone: 559-281-3172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number34194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: