Healthcare Provider Details

I. General information

NPI: 1013176098
Provider Name (Legal Business Name): DANIEL SIMMONDS CANNON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3345 S HARVARD AVE STE 103
TULSA OK
74135-1800
US

IV. Provider business mailing address

3345 S HARVARD AVE STE 103
TULSA OK
74135-1800
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-1351
  • Fax: 918-743-7329
Mailing address:
  • Phone: 918-743-1351
  • Fax: 918-743-7329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number158
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: