Healthcare Provider Details

I. General information

NPI: 1053523647
Provider Name (Legal Business Name): BRENT J. PORTER, D.D.S., M.S., A P.D.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 WATER ST SUITE D NUMBER 1
SANTA CRUZ CA
95060-4124
US

IV. Provider business mailing address

PO BOX 580
APTOS CA
95001-0580
US

V. Phone/Fax

Practice location:
  • Phone: 831-459-9802
  • Fax: 831-459-8234
Mailing address:
  • Phone: 831-459-9802
  • Fax: 831-459-8234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number39322
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number39322
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number39322
License Number StateCA

VIII. Authorized Official

Name: DR. BRENT JOSEPH PORTER
Title or Position: PRESIDENT-DENTIST
Credential: D.D.S., M.S.
Phone: 831-459-9802