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General NPI Number Information
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NPI Number | 1407493760
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Entity Type | Organization
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Legal Business Name | PORTAGE FAMILY DENTISTRY PLLC
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Dates
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Enumeration Date | 12/05/2019
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Last Update Date | 11/20/2024
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Provider Practice Location Address
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Address Line | 1112 E CENTRE AVE
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City | PORTAGE
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State | MI
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Zip | 49002-5575
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Country | US
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Telephone | 269-327-3005
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Fax |
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Provider Business Mailing Address
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Address Line | 1112 E CENTRE AVE
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City | PORTAGE
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State | MI
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Zip | 49002-5575
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Country | US
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Telephone | 269-327-3005
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. ALLISON T CRUTCHFIELD
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Credential | DMD, MPH
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Telephone | 269-830-6609
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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