Provider Demographics
NPI:1487002655
Name:HANNON, CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:HANNON
Suffix:
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 1:1421 WAYZATA BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-4109
Mailing Address - Country:US
Mailing Address - Phone:952-473-1521
Mailing Address - Fax:
Practice Address - Street 1:1421 WAYZATA BLVD STE 300
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-4109
Practice Address - Country:US
Practice Address - Phone:951-473-1521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-29
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13658122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist