Provider Demographics
NPI:1174749097
Name:PORTILLO, ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:PORTILLO
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 1:910 E OHIO AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3438
Mailing Address - Country:US
Mailing Address - Phone:760-747-7223
Mailing Address - Fax:760-747-4288
Practice Address - Street 1:910 E OHIO AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3438
Practice Address - Country:US
Practice Address - Phone:760-747-7223
Practice Address - Fax:760-747-4288
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD216351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice