Provider Demographics
NPI:1396324356
Name:PORTER, GELISE MARIE (DDS)
Entity type:Individual
Prefix:
First Name:GELISE
Middle Name:MARIE
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 1:705 JEFFERSON ST UNIT 114
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70501-6937
Mailing Address - Country:US
Mailing Address - Phone:318-730-3539
Mailing Address - Fax:
Practice Address - Street 1:2807 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-2840
Practice Address - Country:US
Practice Address - Phone:985-602-2716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-06
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX388551223G0001X
390200000X
LA72491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program