Provider Demographics
NPI:1366879728
Name:DEPORTER, AUSTIN JEFFREY (DMD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:JEFFREY
Last Name:DEPORTER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 23RD AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6071
Mailing Address - Country:US
Mailing Address - Phone:970-353-4329
Mailing Address - Fax:
Practice Address - Street 1:1600 23RD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6071
Practice Address - Country:US
Practice Address - Phone:970-353-4329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-01
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029653122300000X
CO00202761122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist