Phennatda Polpornvitoon

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

DN25388 Issued in FL

Practice address

18000 Toledo Blade Blvd
Port Charlotte, FL 33948-1980

Phone

(941) 740-8598

NPI assigned

Apr 24, 2020

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Networks

• Freedom Health HMO Network

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1587686400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1654819200000",
    "number": "1568082030",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "18000 TOLEDO BLADE BLVD",
            "city": "PORT CHARLOTTE",
            "state": "FL",
            "postal_code": "339481980",
            "telephone_number": "954-383-8362"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "18000 TOLEDO BLADE BLVD",
            "city": "PORT CHARLOTTE",
            "state": "FL",
            "postal_code": "339481980",
            "telephone_number": "941-740-8598"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "801 S Paulina St Rm 110",
            "address_purpose": "LOCATION",
            "city": "Chicago",
            "state": "IL",
            "postal_code": "606127210",
            "country_code": "US",
            "telephone_number": "312-996-1052",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "POLPORNVITOON",
        "first_name": "PHENNATDA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-04-24",
        "last_updated": "2022-06-10",
        "certification_date": "2022-06-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "FL",
            "license": "DN25388",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "FL",
            "license": "DN25388",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Stephanie Poitras
• Angelique Renae Polidoro, D.O.
• Rachel Lynn Pollan, BSN DNAP CRNA APRN
• Chanda Pollock, OT
• Jedida Polo Otano
• Yamelys Pons Duran
• Caitlin Marie Pontbriand
• Alina L Popa, M.D.
• Kayla Nicole Pope, PMHNP
• Paul M Popper, M.D.

• General Practice Dentistry in Port Charlotte, FL
• Providers in Port Charlotte, FL by specialty
• General Practice Dentistry in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.