Healthcare Provider Details

I. General information

NPI: 1407090699
Provider Name (Legal Business Name): ROSE MARY PORTER CDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 05/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EMANCIPATION DR
HAMPTON VA
23667-0001
US

IV. Provider business mailing address

PO BOX 1101
FRANKLIN VA
23851-1101
US

V. Phone/Fax

Practice location:
  • Phone: 757-722-9961
  • Fax: 757-728-3138
Mailing address:
  • Phone: 757-653-4213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberCE# 132766
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: