Provider Demographics
NPI:1821406521
Name:CANNON, CASSANDRA LICHKAY (DMD)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LICHKAY
Last Name:CANNON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CASSANDRA
Other - Middle Name:LAREE
Other - Last Name:LICHKAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:3009 CHAPEL HILL ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:770-942-8288
Mailing Address - Fax:
Practice Address - Street 1:3009 CHAPEL HILL ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:770-942-8288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0148451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice