Provider Demographics
NPI:1578307047
Name:CANNON, ANSLEY (DMD)
Entity type:Individual
Prefix:
First Name:ANSLEY
Middle Name:
Last Name:CANNON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 SW 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-8035
Mailing Address - Country:US
Mailing Address - Phone:863-202-6269
Mailing Address - Fax:
Practice Address - Street 1:2200 KINGS HWY UNIT 3I
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33980-5761
Practice Address - Country:US
Practice Address - Phone:941-866-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-20
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist