Provider Demographics
NPI:1720706682
Name:RDG WILLIAM CANNON, PLLC
Entity Type:Organization
Organization Name:RDG WILLIAM CANNON, PLLC
Other - Org Name:ROSE DENTAL GROUP WILLIAM CANNON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:LIGHTFOOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-702-0708
Mailing Address - Street 1:6211 W WILLIAM CANNON DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-1923
Mailing Address - Country:US
Mailing Address - Phone:737-260-3888
Mailing Address - Fax:
Practice Address - Street 1:6211 W WILLIAM CANNON DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78749-1923
Practice Address - Country:US
Practice Address - Phone:737-260-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty