Provider Demographics
NPI:1043008089
Name:PORTSMOUTH PEDIATRIC DENTISTRY PLLC
Entity type:Organization
Organization Name:PORTSMOUTH PEDIATRIC DENTISTRY 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:757-397-9801
Mailing Address - Street 1:446 EFFINGHAM ST STE 400
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3464
Mailing Address - Country:US
Mailing Address - Phone:757-397-9801
Mailing Address - Fax:757-397-9805
Practice Address - Street 1:446 EFFINGHAM ST STE 400
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3464
Practice Address - Country:US
Practice Address - Phone:757-397-9801
Practice Address - Fax:757-397-9805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental