Provider Demographics
NPI:1205061348
Name:PORTER, MAUREEN NICOLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MAUREEN
Middle Name:NICOLE
Last Name:PORTER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 NW IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-1009
Mailing Address - Country:US
Mailing Address - Phone:720-413-0480
Mailing Address - Fax:
Practice Address - Street 1:507 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HILBERT
Practice Address - State:WI
Practice Address - Zip Code:54129
Practice Address - Country:US
Practice Address - Phone:920-853-3212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6232-015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist