Provider Demographics
NPI:1013116979
Name:CANNON, CHRISTOPHER M (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:M
Last Name:CANNON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4968
Mailing Address - Country:US
Mailing Address - Phone:208-524-2300
Mailing Address - Fax:208-545-8447
Practice Address - Street 1:3550 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4968
Practice Address - Country:US
Practice Address - Phone:208-524-2300
Practice Address - Fax:208-545-8447
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9460122300000X
IDD4702122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist