Provider Demographics
NPI:1285843433
Name:CANNON, CALVIN DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:CALVIN
Middle Name:DOUGLAS
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 1:1303 W DUVAL ST
Mailing Address - Street 2:
Mailing Address - City:TROUP
Mailing Address - State:TX
Mailing Address - Zip Code:75789-1509
Mailing Address - Country:US
Mailing Address - Phone:903-842-4600
Mailing Address - Fax:903-842-4600
Practice Address - Street 1:1303 W DUVAL ST
Practice Address - Street 2:
Practice Address - City:TROUP
Practice Address - State:TX
Practice Address - Zip Code:75789-1509
Practice Address - Country:US
Practice Address - Phone:903-842-4600
Practice Address - Fax:903-842-4600
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX92911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice