=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841213782
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT F. CANNIS DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/25/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 RIVER AVE SUITE 3B
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-5657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-367-8200
-----------------------------------------------------
Fax | 732-367-8209
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 RIVER AVE SUITE 3B
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-5657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-367-8200
-----------------------------------------------------
Fax | 732-367-8209
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 22DI01053800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------