Provider Demographics
NPI:1659467785
Name:PORRAS, EDGAR J (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDGAR
Middle Name:J
Last Name:PORRAS
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 1:12251 TAFT ST
Mailing Address - Street 2:SUITE 404
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-1956
Mailing Address - Country:US
Mailing Address - Phone:954-432-7077
Mailing Address - Fax:954-433-0748
Practice Address - Street 1:12251 TAFT ST
Practice Address - Street 2:SUITE 404
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-1956
Practice Address - Country:US
Practice Address - Phone:954-432-7077
Practice Address - Fax:954-433-0748
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00116711223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics