Provider Demographics
NPI:1578581476
Name:CANNON, CHANGA H (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHANGA
Middle Name:H
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 1:7458 S OLYMPIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74132-1838
Mailing Address - Country:US
Mailing Address - Phone:202-489-3661
Mailing Address - Fax:
Practice Address - Street 1:7458 S OLYMPIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74132-1838
Practice Address - Country:US
Practice Address - Phone:202-489-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist