Provider Demographics
NPI:1063757300
Name:CANNON, SARAH CANTY (DMD)
Entity type:Individual
Prefix:DR
First Name:SARAH
Middle Name:CANTY
Last Name:CANNON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9130 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:WEST PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42086-9224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4500 PRISON RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-9011
Practice Address - Country:US
Practice Address - Phone:618-964-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-27
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY90531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice