Provider Demographics
NPI:1649759879
Name:CANNON, STEVEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
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 1:1250 THOMPSON RD
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2538
Mailing Address - Country:US
Mailing Address - Phone:541-269-5353
Mailing Address - Fax:
Practice Address - Street 1:295 S 10TH ST
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-4623
Practice Address - Country:US
Practice Address - Phone:541-269-5353
Practice Address - Fax:541-266-0933
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4949122300000X
ORD110671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD11067OtherOREGON BOARD OF DENTISTRY