Provider Demographics
NPI:1295221778
Name:CANNON, MAXINE (DDS)
Entity type:Individual
Prefix:DR
First Name:MAXINE
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MAXINE
Other - Middle Name:
Other - Last Name:WYKLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1049 N MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3126
Mailing Address - Country:US
Mailing Address - Phone:734-242-4334
Mailing Address - Fax:734-242-0820
Practice Address - Street 1:1049 N MACOMB ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3126
Practice Address - Country:US
Practice Address - Phone:734-242-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-08
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010226731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice