Provider Demographics
NPI:1407090699
Name:PORTER, ROSE MARY (CDA)
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:MARY
Last Name:PORTER
Suffix:
Gender:F
Credentials:CDA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1101
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-1101
Mailing Address - Country:US
Mailing Address - Phone:757-653-4213
Mailing Address - Fax:
Practice Address - Street 1:100 EMANCIPATION DR
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23667-0001
Practice Address - Country:US
Practice Address - Phone:757-722-9961
Practice Address - Fax:757-728-3138
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VACE# 132766126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant