Provider Demographics
NPI:1174580294
Name:TONY PORTER, DDS, PA
Entity type:Organization
Organization Name:TONY PORTER, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROYCE
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-765-9154
Mailing Address - Street 1:3031 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4007
Mailing Address - Country:US
Mailing Address - Phone:336-765-9154
Mailing Address - Fax:336-765-9291
Practice Address - Street 1:3031 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4007
Practice Address - Country:US
Practice Address - Phone:336-765-9154
Practice Address - Fax:336-765-9291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997012Medicaid
NC97012OtherBC/BS PROVIDER ID
NC8997012Medicaid