Provider Demographics
NPI:1205978277
Name:PORTER, JESSE MARK (DMD)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:MARK
Last Name:PORTER
Suffix:
Gender:M
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:PO BOX 853
Mailing Address - Street 2:
Mailing Address - City:FLATWOODS
Mailing Address - State:KY
Mailing Address - Zip Code:41139-0853
Mailing Address - Country:US
Mailing Address - Phone:606-836-7228
Mailing Address - Fax:
Practice Address - Street 1:2104 ARGILLITE RD
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-1620
Practice Address - Country:US
Practice Address - Phone:606-836-7228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY64461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice