MEDICARE: DR. ROYCE ANTHONY PORTER JR. D.D.S.

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	5945	NC

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	BCBS PROVIDER ID

General Provider Information

NPI Number	:	1174581367
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROYCE ANTHONY PORTER JR. D.D.S.

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	07/08/2007

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Directions to “ DR. ROYCE ANTHONY PORTER JR. D.D.S.” Practice Location

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