Provider Demographics
NPI:1497185185
Name:CHANNON, HARRY O SR (DDS)
Entity type:Individual
Prefix:DR
First Name:HARRY
Middle Name:O
Last Name:CHANNON
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8N515 SHADY LN
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-8557
Mailing Address - Country:US
Mailing Address - Phone:847-695-6287
Mailing Address - Fax:
Practice Address - Street 1:8N515 SHADY LN
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124-8557
Practice Address - Country:US
Practice Address - Phone:847-695-6287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0210006391223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry