Provider Demographics
NPI:1184247025
Name:PORT, AUDREY ALANNA (DMD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ALANNA
Last Name:PORT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12455 NATURE EAST DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8049
Mailing Address - Country:US
Mailing Address - Phone:804-432-9728
Mailing Address - Fax:
Practice Address - Street 1:3502 AVALON PARK WEST BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-7859
Practice Address - Country:US
Practice Address - Phone:407-392-9868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN252121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty