Provider Demographics
NPI:1881655710
Name:CANNON, CHRISTOPHER MARK (DDS PC)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:MARK
Last Name:CANNON
Suffix:
Gender:M
Credentials:DDS PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 UTICA RIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722
Mailing Address - Country:US
Mailing Address - Phone:563-359-9165
Mailing Address - Fax:563-359-1824
Practice Address - Street 1:3520 UTICA RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722
Practice Address - Country:US
Practice Address - Phone:563-359-9165
Practice Address - Fax:563-359-1824
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA7498122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1074351Medicaid
IL1001390Medicaid