Provider Demographics
NPI:1518033828
Name:PORT, RICHARD MARK (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MARK
Last Name:PORT
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Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:1 E PHILLIP RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-1858
Mailing Address - Country:US
Mailing Address - Phone:847-367-6068
Mailing Address - Fax:847-367-6079
Practice Address - Street 1:1 E PHILLIP RD
Practice Address - Street 2:SUITE 102
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1858
Practice Address - Country:US
Practice Address - Phone:847-367-6068
Practice Address - Fax:847-367-6079
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics