Provider Demographics
NPI:1083444657
Name:PRIME ORTHODONTICS PLLC
Entity type:Organization
Organization Name:PRIME ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCM
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-327-4843
Mailing Address - Street 1:4525 COLUMBUS ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-7793
Mailing Address - Country:US
Mailing Address - Phone:757-327-4843
Mailing Address - Fax:757-894-8891
Practice Address - Street 1:4525 COLUMBUS ST
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-7793
Practice Address - Country:US
Practice Address - Phone:757-327-4843
Practice Address - Fax:757-894-8891
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIME ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty