Provider Demographics
NPI:1013066265
Name:PORTER, JACKSON LEGGETT (DDS)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:LEGGETT
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 1:4180 DELAWARE
Mailing Address - Street 2:303
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706
Mailing Address - Country:US
Mailing Address - Phone:409-899-2111
Mailing Address - Fax:409-899-2821
Practice Address - Street 1:4180 DELAWARE ST
Practice Address - Street 2:303
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-7858
Practice Address - Country:US
Practice Address - Phone:409-899-2111
Practice Address - Fax:409-899-2821
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist