Provider Demographics
NPI:1396838462
Name:PORTWOOD, JOHN W JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:PORTWOOD
Suffix:JR
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 1:9069 SIEGEN LANE
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810
Mailing Address - Country:US
Mailing Address - Phone:225-766-8278
Mailing Address - Fax:225-767-7226
Practice Address - Street 1:9069 SIEGEN LANE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810
Practice Address - Country:US
Practice Address - Phone:225-766-8278
Practice Address - Fax:225-767-7226
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist