Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 5323-16 | WI |
N | 124Q00000X | Dental Hygienist | H5621 | MN |
NPI | 1063797959 |
---|---|
Provider Name | Ms. Michelle Lee Cannon |
First Address | Superior, WI 54880-3714 |
Second Address | Superior, WI 54880-3714 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2011 |
Last Update Date | 11/10/2011 |