Provider Demographics
NPI:1083813810
Name:CANNON, MARK SMITH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:SMITH
Last Name:CANNON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 ARAPAHOE AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-1023
Mailing Address - Country:US
Mailing Address - Phone:303-444-2129
Mailing Address - Fax:303-413-8145
Practice Address - Street 1:3400 ARAPAHOE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1023
Practice Address - Country:US
Practice Address - Phone:303-444-2129
Practice Address - Fax:303-413-8145
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9352122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist