Provider Demographics
NPI:1629265640
Name:PORTER, CHADWICK HAGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHADWICK
Middle Name:HAGAN
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 1:1633 W MAIN ST # 200
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3423
Mailing Address - Country:US
Mailing Address - Phone:615-449-3222
Mailing Address - Fax:615-449-3202
Practice Address - Street 1:1633 W MAIN ST # 200
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3423
Practice Address - Country:US
Practice Address - Phone:615-449-3222
Practice Address - Fax:615-449-3202
Is Sole Proprietor?:No
Enumeration Date:2007-10-03
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1501181Medicaid