Provider Demographics
NPI:1750636569
Name:PORRAS, LORI BETH (DMD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:BETH
Last Name:PORRAS
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 1:584 STARLIT WAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4322
Mailing Address - Country:US
Mailing Address - Phone:954-383-3893
Mailing Address - Fax:
Practice Address - Street 1:4603 OLEANDER DR STE 3
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5738
Practice Address - Country:US
Practice Address - Phone:843-353-3319
Practice Address - Fax:843-353-3238
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 19624122300000X
SC95671223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist