Provider Demographics
NPI:1063797959
Name:CANNON, MICHELLE LEE (RDH)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:LEE
Last Name:CANNON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2217 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3714
Mailing Address - Country:US
Mailing Address - Phone:218-591-5716
Mailing Address - Fax:
Practice Address - Street 1:2217 E 8TH ST
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3714
Practice Address - Country:US
Practice Address - Phone:218-591-5716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2011-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5323-16124Q00000X
MNH5621124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist