Provider Demographics
NPI:1205417623
Name:KAKARIS PORTER, ALEXANDER ATHANASIOS (DDS)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:ATHANASIOS
Last Name:KAKARIS 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 1:26024 HEATHER LN
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1824
Mailing Address - Country:US
Mailing Address - Phone:734-353-2068
Mailing Address - Fax:
Practice Address - Street 1:21080 ALLEN RD
Practice Address - Street 2:
Practice Address - City:WOODHAVEN
Practice Address - State:MI
Practice Address - Zip Code:48183-1602
Practice Address - Country:US
Practice Address - Phone:734-676-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600905APP211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice