Provider Demographics
NPI:1295049708
Name:CANNONORTHODONTICS
Entity type:Organization
Organization Name:CANNONORTHODONTICS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-289-1989
Mailing Address - Street 1:8500 WILSHIRE BLVD
Mailing Address - Street 2:#1018
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-3121
Mailing Address - Country:US
Mailing Address - Phone:310-289-1989
Mailing Address - Fax:310-289-1661
Practice Address - Street 1:8500 WILSHIRE BLVD
Practice Address - Street 2:#1018
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3121
Practice Address - Country:US
Practice Address - Phone:310-289-1989
Practice Address - Fax:310-289-1661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315821223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty