Provider Demographics
NPI:1699055608
Name:PORCARO, EDILEIA (DMD)
Entity type:Individual
Prefix:
First Name:EDILEIA
Middle Name:
Last Name:PORCARO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 OVER LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-1745
Mailing Address - Country:US
Mailing Address - Phone:770-760-7900
Mailing Address - Fax:770-760-1375
Practice Address - Street 1:1806 OVER LAKE DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-1745
Practice Address - Country:US
Practice Address - Phone:770-760-7900
Practice Address - Fax:770-760-1375
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0143291223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice