Provider Demographics
NPI:1891848610
Name:PORTER, ALLEN STUCKEY (DMD,MS)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:STUCKEY
Last Name:PORTER
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2824 ROGERS RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3895
Mailing Address - Country:US
Mailing Address - Phone:919-435-7660
Mailing Address - Fax:919-453-6370
Practice Address - Street 1:2824 ROGERS RD
Practice Address - Street 2:SUITE 201
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-3895
Practice Address - Country:US
Practice Address - Phone:919-435-7660
Practice Address - Fax:919-453-6370
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC039401223P0221X
SC06471223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3940Medicaid