Provider Demographics
NPI:1568014223
Name:PORTER, DIANA LYNN (RDH)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LYNN
Last Name:PORTER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 WOLF LN
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-9238
Mailing Address - Country:US
Mailing Address - Phone:541-476-9009
Mailing Address - Fax:
Practice Address - Street 1:1705 HAWTHORNE AVE.
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-9752
Practice Address - Country:US
Practice Address - Phone:541-218-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORH3448124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist