Provider Demographics
NPI:1912544768
Name:RUSSELL W. CANNON DDS APC
Entity Type:Organization
Organization Name:RUSSELL W. CANNON DDS APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-552-7874
Mailing Address - Street 1:14150 CULVER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-0322
Mailing Address - Country:US
Mailing Address - Phone:949-552-7874
Mailing Address - Fax:
Practice Address - Street 1:14150 CULVER DR STE 200
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-0322
Practice Address - Country:US
Practice Address - Phone:949-552-7874
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2019-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental