Provider Demographics
NPI:1598381816
Name:PORTER, ROBERT EDWIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EDWIN
Last Name:PORTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12100 BAY TREE WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-5677
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 S SHARON AMITY RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-3871
Practice Address - Country:US
Practice Address - Phone:704-834-1297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-23
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice