Provider Demographics
NPI:1245436187
Name:CLAY D CANNON, DDS, PLLC
Entity type:Organization
Organization Name:CLAY D CANNON, DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLAY
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:903-561-8600
Mailing Address - Street 1:202 SHELLEY DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8725
Mailing Address - Country:US
Mailing Address - Phone:903-561-8600
Mailing Address - Fax:
Practice Address - Street 1:202 SHELLEY DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8725
Practice Address - Country:US
Practice Address - Phone:903-561-8600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX180361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty