Provider Demographics
NPI:1104663962
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:L
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-869-9916
Mailing Address - Street 1:3120 KILN CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:VA
Mailing Address - Zip Code:23693-5648
Mailing Address - Country:US
Mailing Address - Phone:757-327-4843
Mailing Address - Fax:757-234-8891
Practice Address - Street 1:220 NAT TURNER BLVD S
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2998
Practice Address - Country:US
Practice Address - Phone:757-240-5711
Practice Address - Fax:757-240-4939
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty