Provider Demographics
NPI:1699037390
Name:COMBS, PORCHUSA LARAI (DMD)
Entity Type:Individual
Prefix:DR
First Name:PORCHUSA
Middle Name:LARAI
Last Name:COMBS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:464 E BRANDEIS AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-1022
Mailing Address - Country:US
Mailing Address - Phone:502-994-0389
Mailing Address - Fax:
Practice Address - Street 1:982 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40217-1566
Practice Address - Country:US
Practice Address - Phone:502-852-5642
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-09
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY92031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry