Healthcare Provider Details

I. General information

NPI: 1467678938
Provider Name (Legal Business Name): GRANT B. CANNON D.D.S., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 11/11/2021
Certification Date: 11/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 HIGHLAND DR SUITE 112
SALT LAKE CITY UT
84124-2600
US

IV. Provider business mailing address

4190 HIGHLAND DR SUITE 112
SALT LAKE CITY UT
84124-2600
US

V. Phone/Fax

Practice location:
  • Phone: 801-272-9241
  • Fax: 801-277-9760
Mailing address:
  • Phone: 801-272-9241
  • Fax: 801-277-9760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number133953
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: