Provider Demographics
NPI:1639429079
Name:PORT, IGOR M (DDS)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:M
Last Name:PORT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:MR
Other - First Name:IGOR
Other - Middle Name:M
Other - Last Name:PORT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:24-16 QUEENS PLAZA SOUTH
Mailing Address - Street 2:IGOR PORT DDS
Mailing Address - City:LIC
Mailing Address - State:NY
Mailing Address - Zip Code:11101
Mailing Address - Country:US
Mailing Address - Phone:718-205-2020
Mailing Address - Fax:914-242-8599
Practice Address - Street 1:24-16 QUEENS PLAZA SOUTH
Practice Address - Street 2:IGOR PORT DDS
Practice Address - City:LIC
Practice Address - State:NY
Practice Address - Zip Code:11101
Practice Address - Country:US
Practice Address - Phone:718-205-2020
Practice Address - Fax:914-242-8599
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0382811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice