Provider Demographics
NPI:1043351786
Name:PORTER, JESSE PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:PAUL
Last Name:PORTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1391 TOULON ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-6559
Mailing Address - Country:US
Mailing Address - Phone:760-724-9717
Mailing Address - Fax:
Practice Address - Street 1:2310 CRAVEN ST
Practice Address - Street 2:NDMC 32ND ST. BLDG. 3230
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5596
Practice Address - Country:US
Practice Address - Phone:619-556-1581
Practice Address - Fax:619-556-9433
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51189122300000X
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist