Healthcare Provider Details

I. General information

NPI: 1487216842
Provider Name (Legal Business Name): BETINA GRIENS PORTO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2019
Last Update Date: 07/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9601 CHESTER AVENUE CASE WESTERN RESERVE SCHOOL OF DENTAL MEDICINE
CLEVELAND OH
44106
US

IV. Provider business mailing address

24735 TWICKENHAM DR.
BEACHWOOD OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 216-368-4649
  • Fax:
Mailing address:
  • Phone: 216-334-7124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberRES.004158
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: