Provider Demographics
NPI:1497562276
Name:MAXINE CANNON DDS, PLLC
Entity type:Organization
Organization Name:MAXINE CANNON DDS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAXINE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:CANNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-787-8975
Mailing Address - Street 1:1790 EDSEL ST
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1836
Mailing Address - Country:US
Mailing Address - Phone:734-787-8975
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-16
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty