Provider Demographics
NPI:1063404176
Name:CANNON, PATRICIA DEANNE (DDS)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:DEANNE
Last Name:CANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W NEW ORLEANS ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-2218
Mailing Address - Country:US
Mailing Address - Phone:918-455-4242
Mailing Address - Fax:918-455-4244
Practice Address - Street 1:411 W NEW ORLEANS ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74011-2218
Practice Address - Country:US
Practice Address - Phone:918-455-4242
Practice Address - Fax:918-455-4244
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-16
Last Update Date:2007-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OK52181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice