Provider Demographics
NPI:1174581367
Name:PORTER, ROYCE ANTHONY JR (DDS)
Entity type:Individual
Prefix:DR
First Name:ROYCE
Middle Name:ANTHONY
Last Name:PORTER
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC59451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997012Medicaid
NC97012OtherBCBS PROVIDER ID