Provider Demographics
NPI:1801649710
Name:PORTILLO, NATALIE VERONICA
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:VERONICA
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 KENT TOWN MARKET
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619-2632
Mailing Address - Country:US
Mailing Address - Phone:410-643-5500
Mailing Address - Fax:
Practice Address - Street 1:22 KENT TOWN MARKET
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:MD
Practice Address - Zip Code:21619-2632
Practice Address - Country:US
Practice Address - Phone:410-643-5500
Practice Address - Fax:410-643-8538
Is Sole Proprietor?:No
Enumeration Date:2024-04-10
Last Update Date:2025-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MD184911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program