Provider Demographics
NPI:1245430172
Name:PORTER-BASS, NANCY A (RDHAP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:A
Last Name:PORTER-BASS
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:MISS
Other - First Name:NANCY
Other - Middle Name:A
Other - Last Name:GAFFNEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDHAP
Mailing Address - Street 1:25481 DODGE AVE
Mailing Address - Street 2:BDLG. #3
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-3130
Mailing Address - Country:US
Mailing Address - Phone:323-556-1453
Mailing Address - Fax:
Practice Address - Street 1:25481 DODGE AVE.
Practice Address - Street 2:BLDG. #3
Practice Address - City:HARBOR CITY
Practice Address - State:CA
Practice Address - Zip Code:90710-3140
Practice Address - Country:US
Practice Address - Phone:323-556-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA191124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist