Provider Demographics
NPI:1760863096
Name:ZACK PORTER D.D.S. PC
Entity Type:Organization
Organization Name:ZACK PORTER D.D.S. PC
Other - Org Name:SKYLINE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ZACK
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:541-647-4611
Mailing Address - Street 1:1855 NW IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1009
Mailing Address - Country:US
Mailing Address - Phone:541-647-4611
Mailing Address - Fax:
Practice Address - Street 1:2137 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-3824
Practice Address - Country:US
Practice Address - Phone:541-389-4807
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9091122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty