Provider Demographics
NPI:1518481324
Name:PORTER, LATIFAH SERITA
Entity Type:Individual
Prefix:
First Name:LATIFAH
Middle Name:SERITA
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA DENTAL HEALTH ACTIVITY
Mailing Address - Street 2:652 HAMILTON ROAD
Mailing Address - City:FT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503
Mailing Address - Country:US
Mailing Address - Phone:580-442-3905
Mailing Address - Fax:
Practice Address - Street 1:USA DENTAL HEALTH ACTIVITY
Practice Address - Street 2:652 HAMILTON ROAD
Practice Address - City:FT SILL
Practice Address - State:OK
Practice Address - Zip Code:73503
Practice Address - Country:US
Practice Address - Phone:580-442-3905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041438122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist