MEDICARE: DARRIEL JOSEPH CANNON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	13446	NC

General Provider Information

NPI Number	:	1043773427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARRIEL JOSEPH CANNON DDS

Provider Business Mailing Address
First Line	:	14124 ALDENGATE RD
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-6550
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5325 VINNING ST NW STE 203
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28027-2946
Country	:	US
Telephone Number	:	704-785-8060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2019
Last Update Date	:	11/29/2023

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