Healthcare Provider Details

I. General information

NPI: 1083794754
Provider Name (Legal Business Name): RAYMOND EUGENE PORCO JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 E SOUTH BLVD
MONTGOMERY AL
36116
US

IV. Provider business mailing address

6257 MONTICELLO COVE
MONTGOMERY AL
36117
US

V. Phone/Fax

Practice location:
  • Phone: 334-495-2243
  • Fax: 334-495-2244
Mailing address:
  • Phone: 334-213-0716
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD5131
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: