Healthcare Provider Details

I. General information

NPI: 1003733007
Provider Name (Legal Business Name): CANNON JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4323 CHAMPION HILL ST
COLUMBIA SC
29207-6022
US

IV. Provider business mailing address

4050 BEVERLY HILLS DR
PEGRAM TN
37143-2206
US

V. Phone/Fax

Practice location:
  • Phone: 803-751-6213
  • Fax:
Mailing address:
  • Phone: 615-779-3091
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-00237
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: