Provider Demographics
NPI:1417204256
Name:PORTER, JEFF (RDHAP)
Entity Type:Individual
Prefix:MR
First Name:JEFF
Middle Name:
Last Name:PORTER
Suffix:
Gender:M
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11549 SYLVAN ST
Mailing Address - Street 2:#2
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-4086
Mailing Address - Country:US
Mailing Address - Phone:415-847-0546
Mailing Address - Fax:818-505-9717
Practice Address - Street 1:11549 SYLVAN ST
Practice Address - Street 2:#2
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-4086
Practice Address - Country:US
Practice Address - Phone:415-847-0546
Practice Address - Fax:818-505-9717
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-10
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA432124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist