Provider Demographics
NPI:1083763668
Name:PORTER, RYAN JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:JOSEPH
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 1:3330 N. UNIVERSITY AVE. STE A
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-4454
Mailing Address - Country:US
Mailing Address - Phone:801-615-2917
Mailing Address - Fax:801-960-3643
Practice Address - Street 1:3330 N. UNIVERSITY AVE. STE A
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-4454
Practice Address - Country:US
Practice Address - Phone:801-960-3643
Practice Address - Fax:801-960-3643
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ61101223G0001X
UT11632110-99211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice