Provider Demographics
NPI:1831327907
Name:PORT, IRA S (DMD)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:S
Last Name:PORT
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 1:2341 HIGHWAY 66
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3961
Mailing Address - Country:US
Mailing Address - Phone:732-922-2222
Mailing Address - Fax:732-922-2969
Practice Address - Street 1:2341 HIGHWAY 66
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-3961
Practice Address - Country:US
Practice Address - Phone:732-922-2255
Practice Address - Fax:732-922-2969
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11460122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist