MEDICARE: DR. DOVARD THOMAS PORTER JR. DMD

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	4138	KY

General Provider Information

NPI Number	:	1942420518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOVARD THOMAS PORTER JR. DMD

Provider Business Mailing Address
First Line	:	542 NOEL DR
Second Line	:
City	:	HOPKINSVILLE
State	:	KY
Zip	:	42240-1386
Country	:	US
Telephone Number	:	270-885-6137
Fax Number	:	270-885-2629

Provider Business Practice Location Address
First Line	:	542 NOEL DR
Second Line	:
City	:	HOPKINSVILLE
State	:	KY
Zip	:	42240-1386
Country	:	US
Telephone Number	:	270-885-6137
Fax Number	:	270-885-2629

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	10/23/2008

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