Healthcare Provider Details

I. General information

NPI: 1295049708
Provider Name (Legal Business Name): CANNONORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 WILSHIRE BLVD #1018
BEVERLY HILLS CA
90211-3121
US

IV. Provider business mailing address

8500 WILSHIRE BLVD #1018
BEVERLY HILLS CA
90211-3121
US

V. Phone/Fax

Practice location:
  • Phone: 310-289-1989
  • Fax: 310-289-1661
Mailing address:
  • Phone: 310-289-1989
  • Fax: 310-289-1661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number31582
License Number StateCA

VIII. Authorized Official

Name: DR. WILLIAM J CANNON
Title or Position: OWNER/DENTIST
Credential: D.D.S.
Phone: 310-289-1989