Provider Demographics
NPI:1801824040
Name:CANNON, DAVID L (DDS)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:L
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 1:4100 SHORELINE DR. #4
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384
Mailing Address - Country:US
Mailing Address - Phone:952-224-9784
Mailing Address - Fax:952-224-9791
Practice Address - Street 1:3015 HWY 29 S.
Practice Address - Street 2:SUITE 4176
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308
Practice Address - Country:US
Practice Address - Phone:320-763-5052
Practice Address - Fax:320-763-5053
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN118681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN537439100OtherMN HEALTH PLANS PROVIDER