Provider Demographics
NPI:1003234360
Name:PREMIERE ORTHO-PEDO PLLC
Entity Type:Organization
Organization Name:PREMIERE ORTHO-PEDO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:BONFUAN
Authorized Official - Last Name:NGWAFON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-725-7735
Mailing Address - Street 1:PO BOX 55474
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20040-5474
Mailing Address - Country:US
Mailing Address - Phone:202-725-7735
Mailing Address - Fax:
Practice Address - Street 1:437 CEDAR ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-1931
Practice Address - Country:US
Practice Address - Phone:202-725-7735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-03
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN10013491223P0221X
DCDEN10009971223X0400X
1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty