Healthcare Provider Details

I. General information

NPI: 1104663962
Provider Name (Legal Business Name): PRIME ORTHODONTICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 NAT TURNER BLVD S
NEWPORT NEWS VA
23606-2998
US

IV. Provider business mailing address

3120 KILN CREEK PKWY
YORKTOWN VA
23693-5648
US

V. Phone/Fax

Practice location:
  • Phone: 757-240-5711
  • Fax: 757-240-4939
Mailing address:
  • Phone: 757-327-4843
  • Fax: 757-234-8891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHRIS L CANNON
Title or Position: RCM
Credential:
Phone: 757-869-9916