MEDICARE: DR. MARY ISABELLE PORTER D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	9698	FL

General Provider Information

NPI Number	:	1467679407
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ISABELLE PORTER D.M.D

Provider Business Mailing Address
First Line	:	4987 RINGWOOD MEADOW
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34235-2033
Country	:	US
Telephone Number	:	941-377-3659
Fax Number	:	941-378-0893

Provider Business Practice Location Address
First Line	:	4987 RINGWOOD MEADOW
Second Line	:
City	:	SARASOTA
State	:	FL
Zip	:	34235-2033
Country	:	US
Telephone Number	:	941-377-3659
Fax Number	:	941-378-0893

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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