Provider Demographics
NPI:1114617982
Name:KINCANNON, JOSHUA LEE
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:LEE
Last Name:KINCANNON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12600 AUTUMN OAKS LN
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003-7762
Mailing Address - Country:US
Mailing Address - Phone:530-356-8969
Mailing Address - Fax:
Practice Address - Street 1:29632 E HIGHWAY 299
Practice Address - Street 2:
Practice Address - City:ROUND MOUNTAIN
Practice Address - State:CA
Practice Address - Zip Code:96084-8000
Practice Address - Country:US
Practice Address - Phone:530-337-5750
Practice Address - Fax:530-232-9602
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA110518122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program