Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 019-024825 | IL |
NPI | 1003954819 |
---|---|
Provider Name | Dr. Melissa Ann Porter |
First Address | Carbondale, IL 62901-5217 |
Second Address | East Peoria, IL 61611-2550 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/02/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
019-024825 | (05) | IL |