Provider Demographics
NPI:1053523647
Name:BRENT J. PORTER, D.D.S., M.S., A P.D.C.
Entity type:Organization
Organization Name:BRENT J. PORTER, D.D.S., M.S., A P.D.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:831-459-9802
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95001-0580
Mailing Address - Country:US
Mailing Address - Phone:831-459-9802
Mailing Address - Fax:831-459-8234
Practice Address - Street 1:550 WATER ST
Practice Address - Street 2:SUITE D NUMBER 1
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-4124
Practice Address - Country:US
Practice Address - Phone:831-459-9802
Practice Address - Fax:831-459-8234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA393221223G0001X, 1223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB39322OtherDENTICAL