Provider Demographics
NPI:1467678938
Name:CANNON, GRANT B (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:GRANT
Middle Name:B
Last Name:CANNON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4190 HIGHLAND DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-2600
Mailing Address - Country:US
Mailing Address - Phone:801-272-9241
Mailing Address - Fax:801-277-9760
Practice Address - Street 1:4190 HIGHLAND DR
Practice Address - Street 2:SUITE 112
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2600
Practice Address - Country:US
Practice Address - Phone:801-272-9241
Practice Address - Fax:801-277-9760
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1339531223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery