Provider Demographics
NPI:1003272444
Name:PORTER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 E LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-2478
Mailing Address - Country:US
Mailing Address - Phone:509-837-1778
Mailing Address - Fax:509-837-3117
Practice Address - Street 1:1721 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2478
Practice Address - Country:US
Practice Address - Phone:509-837-7178
Practice Address - Fax:509-837-3117
Is Sole Proprietor?:No
Enumeration Date:2016-01-14
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04420002501223X0400X
WADE609361981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics