Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 12011510A | IN |
NPI | 1003122474 |
---|---|
Provider Name | Dr. Benjamin Lloyd Porter |
First Address | La Porte, IN 46350-3175 |
Second Address | La Porte, IN 46350-3175 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/08/2010 |
Last Update Date | 24/08/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200237780A | (05) | IN |