Provider Demographics
NPI:1851315782
Name:PORTER, JOHN MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:PORTER
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 1:8202 CLEARVISTA PKWY
Mailing Address - Street 2:BUILDING 5 SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1400
Mailing Address - Country:US
Mailing Address - Phone:317-842-6333
Mailing Address - Fax:
Practice Address - Street 1:8202 CLEARVISTA PKWY
Practice Address - Street 2:BUILDING 5 SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1400
Practice Address - Country:US
Practice Address - Phone:317-842-6333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007054A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery