Provider Demographics
NPI:1174524870
Name:PORTACCI, KRISTOPHER ANTHONY (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTOPHER
Middle Name:ANTHONY
Last Name:PORTACCI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 NORTH FLORIDA STREET
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36607-3108
Mailing Address - Country:US
Mailing Address - Phone:251-478-9164
Mailing Address - Fax:251-473-5618
Practice Address - Street 1:2 NORTH FLORIDA STREET
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36607-3108
Practice Address - Country:US
Practice Address - Phone:251-478-9164
Practice Address - Fax:251-473-5618
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL55961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice