Provider Demographics
NPI:1003954819
Name:PORTER, MELISSA ANN (DMD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:ANN
Last Name:PORTER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:MELISSA
Other - Middle Name:ANN
Other - Last Name:MORLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2905 W ALVERIA DR
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5217
Mailing Address - Country:US
Mailing Address - Phone:618-549-7872
Mailing Address - Fax:618-549-7872
Practice Address - Street 1:134 MCKINLEY ST
Practice Address - Street 2:
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-2550
Practice Address - Country:US
Practice Address - Phone:309-699-6770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-024825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019-024825Medicaid