Provider Demographics
NPI:1134331887
Name:PORTER, BRENT JOSEPH (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:JOSEPH
Last Name:PORTER
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95001-0580
Mailing Address - Country:US
Mailing Address - Phone:831-459-9802
Mailing Address - Fax:831-459-8234
Practice Address - Street 1:550 WATER ST
Practice Address - Street 2:SUITE D, NUMBER 1
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4124
Practice Address - Country:US
Practice Address - Phone:831-459-9802
Practice Address - Fax:831-459-8234
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393221223G0001X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223G0001XDental ProvidersDentistGeneral Practice
Not Answered1223P0221XDental ProvidersDentistPediatric Dentistry
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB39322OtherDENTI-CAL