Provider Demographics
NPI:1578650586
Name:CANON, DENNIS LANE (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:LANE
Last Name:CANON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 4TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-4051
Mailing Address - Country:US
Mailing Address - Phone:806-655-1191
Mailing Address - Fax:806-655-1192
Practice Address - Street 1:2001 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:CANYON
Practice Address - State:TX
Practice Address - Zip Code:79015-4051
Practice Address - Country:US
Practice Address - Phone:806-655-1191
Practice Address - Fax:806-655-1192
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9481207Q00000X
NM81173207Q00000X
AZ7973207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000TP67OtherBC
00TP67Medicare ID - Type Unspecified
C14150Medicare UPIN