Provider Demographics
NPI:1104284843
Name:PORTER, MELANIE LATRICE (DDS)
Entity type:Individual
Prefix:DR
First Name:MELANIE
Middle Name:LATRICE
Last Name:PORTER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MELANIE
Other - Middle Name:LATRICE
Other - Last Name:WALKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:606 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-2028
Mailing Address - Country:US
Mailing Address - Phone:478-746-4578
Mailing Address - Fax:478-745-6413
Practice Address - Street 1:606 SPRING ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2028
Practice Address - Country:US
Practice Address - Phone:478-746-4578
Practice Address - Fax:478-745-6413
Is Sole Proprietor?:No
Enumeration Date:2016-02-09
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0151171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice