Healthcare Provider Details

I. General information

NPI: 1265272215
Provider Name (Legal Business Name): COLLIN PORTER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S IDAHO RD STE 260
APACHE JUNCTION AZ
85119-2379
US

IV. Provider business mailing address

1911 E PARK AVE
GILBERT AZ
85234-6107
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-0782
  • Fax:
Mailing address:
  • Phone: 480-577-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD012155
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: