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General NPI Number Information
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NPI Number | 1053523647
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Entity Type | Organization
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Legal Business Name | BRENT J. PORTER, D.D.S., M.S., A P.D.C.
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 550 WATER ST SUITE D NUMBER 1
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City | SANTA CRUZ
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State | CA
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Zip | 95060-4124
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Country | US
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Telephone | 831-459-9802
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Fax | 831-459-8234
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Provider Business Mailing Address
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Address Line | PO BOX 580
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City | APTOS
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State | CA
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Zip | 95001-0580
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Country | US
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Telephone | 831-459-9802
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Fax | 831-459-8234
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Authorized Official
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Title or Position | PRESIDENT-DENTIST
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Name | DR. BRENT JOSEPH PORTER
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Credential | D.D.S., M.S.
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Telephone | 831-459-9802
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 39322
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 39322
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 39322
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License Number State | CA
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