Provider Demographics
NPI:1700631801
Name:COLISEUM PEDIATRIC DENTISTRY SURGERY CENTER
Entity Type:Organization
Organization Name:COLISEUM PEDIATRIC DENTISTRY SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RCM
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-327-4843
Mailing Address - Street 1:2113 HARTFORD RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-2575
Mailing Address - Country:US
Mailing Address - Phone:757-838-0800
Mailing Address - Fax:
Practice Address - Street 1:2113 HARTFORD RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-2575
Practice Address - Country:US
Practice Address - Phone:757-327-7843
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLISEUM PEDIATRIC DENTISTRY PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-22
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty