Provider Demographics
NPI:1891731121
Name:CANNON, MARK L (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:L
Last Name:CANNON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 RFD
Mailing Address - Street 2:GROVE MEDICAL CENTER
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-9586
Mailing Address - Country:US
Mailing Address - Phone:847-634-6166
Mailing Address - Fax:
Practice Address - Street 1:4160 RFD
Practice Address - Street 2:GROVE MEDICAL CENTER, SUITE 308
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-9583
Practice Address - Country:US
Practice Address - Phone:847-634-6166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry