Provider Demographics
NPI:1538464482
Name:PORTO, FELIPE (DDS, MS, MSD)
Entity Type:Individual
Prefix:
First Name:FELIPE
Middle Name:
Last Name:PORTO
Suffix:
Gender:M
Credentials:DDS, MS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 44TH ST SW STE 101
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2300
Mailing Address - Country:US
Mailing Address - Phone:616-743-6569
Mailing Address - Fax:
Practice Address - Street 1:4320 44TH ST SW STE 101
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2300
Practice Address - Country:US
Practice Address - Phone:616-743-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016007331223X0400X
CT20104451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics