Provider Demographics
NPI:1417457524
Name:PORTER, BLAKE CARDON (DMD)
Entity Type:Individual
Prefix:MR
First Name:BLAKE
Middle Name:CARDON
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 1:3377 W LAZY J LN
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6337
Mailing Address - Country:US
Mailing Address - Phone:480-273-4544
Mailing Address - Fax:
Practice Address - Street 1:3377 W LAZY J LN
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-6337
Practice Address - Country:US
Practice Address - Phone:480-273-4544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5568-OS1223S0112X
IARES-30526390200000X
UT7821520-99251223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program