Healthcare Provider Details

I. General information

NPI: 1346166345
Provider Name (Legal Business Name): CANNON FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4720 W URBANA ST
BROKEN ARROW OK
74012-5997
US

IV. Provider business mailing address

4720 W URBANA ST
BROKEN ARROW OK
74012-5997
US

V. Phone/Fax

Practice location:
  • Phone: 918-455-4242
  • Fax: 918-455-4244
Mailing address:
  • Phone: 918-455-4242
  • Fax: 918-455-4244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA CANNON
Title or Position: DENTIST
Credential:
Phone: 918-455-4242