Provider Demographics
NPI:1093929556
Name:DELLA PORTA, RAYMOND A (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:A
Last Name:DELLA PORTA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 36TH ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4898
Mailing Address - Country:US
Mailing Address - Phone:772-567-1025
Mailing Address - Fax:772-778-6597
Practice Address - Street 1:1300 36TH ST
Practice Address - Street 2:SUITE F
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4898
Practice Address - Country:US
Practice Address - Phone:772-567-1025
Practice Address - Fax:772-778-6597
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL4552122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL4552OtherSTATE LICENSE NUMBER