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Individual
MR. BLAKE CARDON PORTER
Active
Individual
MR. BLAKE CARDON PORTER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
7821520-9925
UT
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
D-5568-OS
ID
390200000X
Student in an Organized Health Care Education/Training Program
RES-30526
IA
Other
Enumeration date
02/15/2018
Last updated
12/08/2023
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