Provider Demographics
NPI:1225143720
Name:CANNON, JOHN SHRADER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SHRADER
Last Name:CANNON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1661 AARON BRENNER DR STE 105
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-1467
Mailing Address - Country:US
Mailing Address - Phone:901-756-8475
Mailing Address - Fax:901-756-7820
Practice Address - Street 1:1661 AARON BRENNER DR STE 105
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-1467
Practice Address - Country:US
Practice Address - Phone:901-756-8475
Practice Address - Fax:901-756-7820
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS27521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000516OtherASSURANT #
TN113786OtherCIGNA #
TN532822OtherUNITED CONCORDIA #
TN606051OtherCOMPBENEFITS #
TN2038634OtherAETNA #
TN4079273OtherBLUE CROSS BLUE SHIELD
TN532822OtherUNITED CONCORDIA #
TNT74379Medicare UPIN