Provider Demographics
NPI:1063078210
Name:CANNON, CARSON (DDS)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:CANNON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2850 CURVE CREST BLVD W
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-4039
Mailing Address - Country:US
Mailing Address - Phone:651-439-9400
Mailing Address - Fax:
Practice Address - Street 1:2850 CURVE CREST BLVD W STE 200
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-4073
Practice Address - Country:US
Practice Address - Phone:651-439-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14174122300000X, 1223G0001X
WI1002126-151223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice