Healthcare Provider Details

I. General information

NPI: 1689628604
Provider Name (Legal Business Name): PORTER, MARTIN, SALMAN, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 BRICK RD WEST JERSEY MEDICAL PLAZA STE. 100
MARLTON NJ
08053-2179
US

IV. Provider business mailing address

94 BRICK RD WEST JERSEY MEDICAL PLAZA STE. 100
MARLTON NJ
08053-2179
US

V. Phone/Fax

Practice location:
  • Phone: 856-596-9099
  • Fax: 856-983-5946
Mailing address:
  • Phone: 856-596-9099
  • Fax: 856-983-5946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDI14482
License Number StateNJ

VIII. Authorized Official

Name: DR. BRADFORD J. PORTER
Title or Position: PRESIDENT
Credential: DDS
Phone: 856-596-9099