Provider Demographics
NPI:1437286390
Name:PORTER, LAWRENCE THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:THOMAS
Last Name:PORTER
Suffix:
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 1:309 N 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3242
Mailing Address - Country:US
Mailing Address - Phone:262-338-1164
Mailing Address - Fax:262-338-1646
Practice Address - Street 1:309 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3242
Practice Address - Country:US
Practice Address - Phone:262-338-1164
Practice Address - Fax:262-338-1646
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice