Healthcare Provider Details

I. General information

NPI: 1104896398
Provider Name (Legal Business Name): THOMAS JOSEPH CANAAN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BUILDING 964 ENTERPRISE ST
JACKSONVILLE FL
32214-0001
US

IV. Provider business mailing address

2080 CHILD ST
JACKSONVILLE FL
32214-5005
US

V. Phone/Fax

Practice location:
  • Phone: 904-542-3441
  • Fax:
Mailing address:
  • Phone: 904-542-3441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number0401006620
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: