1366758419 NPI number — DR. TERRIN MELVIN PORTER D.D.S.

Table of content: DR. TERRIN MELVIN PORTER D.D.S. (NPI 1366758419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366758419 NPI number — DR. TERRIN MELVIN PORTER D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTER
Provider First Name:
TERRIN
Provider Middle Name:
MELVIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366758419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
92242 US HIGHWAY 89
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROVER
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
83122-8803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-602-8678
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 E MAIN ST STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVERTON
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82501-4350
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-602-8678
Provider Business Practice Location Address Fax Number:
307-237-4424
Provider Enumeration Date:
08/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  1253 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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