MEDICARE: TONY PORTER, DDS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	97012	OTHER	NC	BC/BS PROVIDER ID

General Provider Information

NPI Number	:	1174580294
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TONY PORTER, DDS, PA

Provider Business Mailing Address
First Line	:	3031 LYNDHURST AVE
Second Line	:
City	:	WINSTON-SALEM
State	:	NC
Zip	:	27103-4007
Country	:	US
Telephone Number	:	336-765-9154
Fax Number	:	336-765-9291

Provider Business Practice Location Address
First Line	:	3031 LYNDHURST AVE
Second Line	:
City	:	WINSTON-SALEM
State	:	NC
Zip	:	27103-4007
Country	:	US
Telephone Number	:	336-765-9154
Fax Number	:	336-765-9291

Authorized Official
Title or Position	:	DENTIST/PRESIDENT
Name	:	DR. ROYCE ANTHONY PORTER JR.
Credential	:	D.D.S.
Telephone Number	:	336-765-9154

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	08/22/2020

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