Provider Demographics
NPI:1235546664
Name:PORTER, MACKENZIE
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MAHOGANY LN
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-6922
Mailing Address - Country:US
Mailing Address - Phone:775-230-5461
Mailing Address - Fax:
Practice Address - Street 1:1920 OUTLET CENTER DR
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-0677
Practice Address - Country:US
Practice Address - Phone:702-671-5134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-17
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLL-377-14122300000X
CA65067122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist