Healthcare Provider Details

I. General information

NPI: 1477255859
Provider Name (Legal Business Name): RADIANT FLUX PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 BRIDGEPORT WAY STE 109
SUFFOLK VA
23435-1960
US

IV. Provider business mailing address

1301 BRIDGEPORT WAY STE 109
SUFFOLK VA
23435-1960
US

V. Phone/Fax

Practice location:
  • Phone: 757-929-7100
  • Fax: 757-929-7097
Mailing address:
  • Phone: 757-929-7100
  • Fax: 757-929-7097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN GENE BRIESEMEISTER
Title or Position: EXECUTIVE
Credential: DDS
Phone: 757-929-7100