Provider Demographics
NPI:1083609010
Name:PORTER, GARY L (DDS)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:L
Last Name:PORTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5712 SPRINGBORO PIKE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2842
Mailing Address - Country:US
Mailing Address - Phone:937-298-9911
Mailing Address - Fax:937-298-7899
Practice Address - Street 1:5712 SPRINGBORO PIKE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45449-2842
Practice Address - Country:US
Practice Address - Phone:937-298-9911
Practice Address - Fax:937-298-7899
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36161091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice