Provider Demographics
NPI:1881765717
Name:CANNON, KATHLEEN SUE (DDS)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:SUE
Last Name:CANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14736 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-3626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-2203
Practice Address - Country:US
Practice Address - Phone:918-594-4860
Practice Address - Fax:918-594-4889
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK45931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice