Provider Demographics
NPI:1649387986
Name:CANNON, RUSSELL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WAYNE
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 1:14150 CULVER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-0322
Mailing Address - Country:US
Mailing Address - Phone:949-552-7874
Mailing Address - Fax:949-552-7047
Practice Address - Street 1:14150 CULVER DR STE 200
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-0322
Practice Address - Country:US
Practice Address - Phone:949-552-7874
Practice Address - Fax:949-552-7047
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD242791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice