=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508908146
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COREY J PORCHE DDS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2007
-----------------------------------------------------
Last Update Date | 04/23/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 WESTSIDE BLVD
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-876-2439
-----------------------------------------------------
Fax | 985-879-4869
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 114 WESTSIDE BLVD
-----------------------------------------------------
City | HOUMA
-----------------------------------------------------
State | LA
-----------------------------------------------------
Zip | 70364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 985-876-2439
-----------------------------------------------------
Fax | 985-879-4869
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | MR. COREY J PORCHE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 985-876-2439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5582
-----------------------------------------------------
License Number State | LA
-----------------------------------------------------