Provider Demographics
NPI:1164764882
Name:WILLIAM CANNON FAMILY DENTAL PC
Entity Type:Organization
Organization Name:WILLIAM CANNON FAMILY DENTAL PC
Other - Org Name:KIDZ DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-326-3473
Mailing Address - Street 1:500 W WILLIAM CANNON DR STE 438A
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745-5853
Mailing Address - Country:US
Mailing Address - Phone:512-326-3473
Mailing Address - Fax:
Practice Address - Street 1:500 W WILLIAM CANNON DR STE 438A
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5853
Practice Address - Country:US
Practice Address - Phone:512-326-3473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-20
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX242471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty