Provider Demographics
NPI:1124126248
Name:PORTER, JO LYNN (DDS)
Entity type:Individual
Prefix:
First Name:JO LYNN
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 COLLEYVILLE BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-3932
Mailing Address - Country:US
Mailing Address - Phone:817-410-8899
Mailing Address - Fax:817-514-6003
Practice Address - Street 1:4601 COLLEYVILLE BLVD STE 140
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-3932
Practice Address - Country:US
Practice Address - Phone:817-410-8899
Practice Address - Fax:817-514-6003
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist