Provider Demographics
NPI:1659650828
Name:PORTER, GARTH THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARTH
Middle Name:THOMAS
Last Name:PORTER
Suffix:
Gender:M
Credentials:DDS
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Mailing Address - Street 1:2441 21ST ST
Mailing Address - Street 2:US ARMY DENTAL L ACTIVITY
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5582
Mailing Address - Country:US
Mailing Address - Phone:270-798-8751
Mailing Address - Fax:270-956-0266
Practice Address - Street 1:2441 21ST ST
Practice Address - Street 2:US ARMY DENTAL L ACTIVITY
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5582
Practice Address - Country:US
Practice Address - Phone:270-798-8751
Practice Address - Fax:270-956-0266
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT8046391-99211223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223G0001XDental ProvidersDentistGeneral Practice