MEDICARE: LESTER W CANNON DDS PC

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	1223G0001X	General Practice Dentistry	1364589922	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427278019
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LESTER W CANNON DDS PC

Provider Business Mailing Address
First Line	:	1935 E 5600 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1351
Country	:	US
Telephone Number	:	801-277-4049
Fax Number	:	801-277-9773

Provider Business Practice Location Address
First Line	:	1935 E 5600 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1351
Country	:	US
Telephone Number	:	801-277-4049
Fax Number	:	801-277-9773

Authorized Official
Title or Position	:	OWNER
Name	:	DR. LESTER W CANNON
Credential	:	D.D.S.
Telephone Number	:	801-277-4049

Provider Enumeration Date	:	04/26/2007
Last Update Date	:	04/12/2012

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