Provider Demographics
NPI:1629305065
Name:CANNON, MICHELLE LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LYNN
Last Name:CANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 FRANKLIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-3563
Mailing Address - Country:US
Mailing Address - Phone:219-872-6200
Mailing Address - Fax:219-379-2736
Practice Address - Street 1:710 FRANKLIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-3563
Practice Address - Country:US
Practice Address - Phone:219-872-6200
Practice Address - Fax:219-379-2736
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2012-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0281401223G0001X
IN12011767A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice