Provider Demographics
NPI:1467573626
Name:PORTER, JACK CLARK (DDS)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:CLARK
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 1:1919 MALVERN AVE
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-7753
Mailing Address - Country:US
Mailing Address - Phone:501-624-2778
Mailing Address - Fax:501-321-9774
Practice Address - Street 1:1919 MALVERN AVE
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-7753
Practice Address - Country:US
Practice Address - Phone:501-624-2778
Practice Address - Fax:501-321-9774
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR21331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice