Provider Demographics
NPI:1275669798
Name:PORTER, MARK F (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:F
Last Name:PORTER
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 1:9 RACHAEL CT
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-4010
Mailing Address - Country:US
Mailing Address - Phone:618-667-8852
Mailing Address - Fax:
Practice Address - Street 1:212 E MARKET ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-1512
Practice Address - Country:US
Practice Address - Phone:618-667-6101
Practice Address - Fax:618-667-8099
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19.0156951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice