Provider Demographics
NPI:1619965407
Name:PORTER, BRADFORD J (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:J
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 1:94 BRICK RD
Mailing Address - Street 2:WEST JERSEY MEDICAL PLAZA SUITE 100
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2179
Mailing Address - Country:US
Mailing Address - Phone:856-596-9099
Mailing Address - Fax:856-596-6715
Practice Address - Street 1:94 BRICK RD
Practice Address - Street 2:WEST JERSEY MEDICAL PLAZA SUITE 100
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2179
Practice Address - Country:US
Practice Address - Phone:856-596-9099
Practice Address - Fax:856-596-6715
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI144821223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1126903Medicaid
NJ091839Medicare ID - Type Unspecified
NJU01551Medicare UPIN