Provider Demographics
NPI:1407101033
Name:PORTER, IRIVELISSE STEVENS (DMD)
Entity Type:Individual
Prefix:DR
First Name:IRIVELISSE
Middle Name:STEVENS
Last Name:PORTER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5077 CREEK CROSSING DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32226-4779
Mailing Address - Country:US
Mailing Address - Phone:904-463-4531
Mailing Address - Fax:
Practice Address - Street 1:12086 FORT CAROLINE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-2687
Practice Address - Country:US
Practice Address - Phone:904-807-9127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL197141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice