=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114141603
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN GANNON DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 880 COMMERCE DR
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-874-3129
-----------------------------------------------------
Fax | 419-874-5007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 880 COMMERCE DR
-----------------------------------------------------
City | PERRYSBURG
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43551-5240
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-874-3129
-----------------------------------------------------
Fax | 419-874-5007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 17571
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------