MEDICARE: PAUL E. PRILLAMAN, III, DDS, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QS0112X	Oral and Maxillofacial Surgery Clinic/Center

General Provider Information

NPI Number	:	1215292255
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PAUL E. PRILLAMAN, III, DDS, PLC

Provider Business Mailing Address
First Line	:	905 BATTLEFIELD BLVD N STE 101
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-4875
Country	:	US
Telephone Number	:	757-547-2820
Fax Number	:	757-547-4301

Provider Business Practice Location Address
First Line	:	905 BATTLEFIELD BLVD N
Second Line	:	101
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-4875
Country	:	US
Telephone Number	:	757-547-2820
Fax Number	:	757-547-4301

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. PAUL ELLIS PRILLAMAN III
Credential	:	DDS
Telephone Number	:	757-547-2820

Provider Enumeration Date	:	07/05/2012
Last Update Date	:	07/05/2012

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