Provider Demographics
NPI:1497915219
Name:PORTER, STEPHEN WARREN (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:WARREN
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 1:76 NEALY AVE
Mailing Address - Street 2:1ST DENTAL SQUADRON/SGD
Mailing Address - City:LANGLEY AIR FORCE BASE
Mailing Address - State:VA
Mailing Address - Zip Code:23665
Mailing Address - Country:US
Mailing Address - Phone:757-764-9643
Mailing Address - Fax:
Practice Address - Street 1:76 NEALY AVE
Practice Address - Street 2:1ST DENTAL SQUADRON/SGD
Practice Address - City:LANGLEY AIR FORCE BASE
Practice Address - State:VA
Practice Address - Zip Code:23665
Practice Address - Country:US
Practice Address - Phone:757-764-9643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice