Provider Demographics
NPI:1265272215
Name:PORTER, COLLIN (DMD)
Entity type:Individual
Prefix:
First Name:COLLIN
Middle Name:
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 1:1911 E PARK AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-6107
Mailing Address - Country:US
Mailing Address - Phone:480-577-5687
Mailing Address - Fax:
Practice Address - Street 1:110 S IDAHO RD STE 260
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85119-2379
Practice Address - Country:US
Practice Address - Phone:480-982-0782
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0121551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice