Provider Demographics
NPI:1437438579
Name:DANIEL CANNON, DDS, ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:DANIEL CANNON, DDS, ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:SIMMONDS
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:918-743-1351
Mailing Address - Street 1:4608 S HARVARD AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2913
Mailing Address - Country:US
Mailing Address - Phone:918-743-1351
Mailing Address - Fax:918-743-7329
Practice Address - Street 1:4608 S HARVARD AVE
Practice Address - Street 2:SUITE C
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2913
Practice Address - Country:US
Practice Address - Phone:918-743-1351
Practice Address - Fax:918-743-7329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1581223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty