Basic Information
| Provider Information | |||||||||
| NPI: | 1568776185 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTUESE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 CAREY RD | ||||||||
| Address2: | |||||||||
| City: | QUEENSBURY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128047880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5187610300 | ||||||||
| FaxNumber: | 5188242388 | ||||||||
| Practice Location | |||||||||
| Address1: | 3761 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WARRENSBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 128851837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5186233918 | ||||||||
| FaxNumber: | 5186234330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2010 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 055052 | NY | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 03294451 | 05 | NY | MEDICAID |