MEDICARE: DR. LESTER WILLIAM CANNON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	136458	UT

General Provider Information

NPI Number	:	1326305517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LESTER WILLIAM CANNON D.D.S.

Provider Business Mailing Address
First Line	:	714 FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-2347
Country	:	US
Telephone Number	:	801-277-4049
Fax Number	:	801-566-5725

Provider Business Practice Location Address
First Line	:	714 FORT UNION BLVD
Second Line	:
City	:	MIDVALE
State	:	UT
Zip	:	84047-2347
Country	:	US
Telephone Number	:	801-277-4049
Fax Number	:	801-566-5725

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2012
Last Update Date	:	04/12/2012

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