Healthcare Provider Details

I. General information

NPI: 1891731121
Provider Name (Legal Business Name): MARK L CANNON DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 RFD GROVE MEDICAL CENTER, SUITE 308
LONG GROVE IL
60047-9583
US

IV. Provider business mailing address

4160 RFD GROVE MEDICAL CENTER
LONG GROVE IL
60047-9586
US

V. Phone/Fax

Practice location:
  • Phone: 847-634-6166
  • Fax:
Mailing address:
  • Phone: 847-634-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: