Provider Demographics
NPI:1053600601
Name:CHANNER, JONATHAN ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:CHANNER
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 1:300 W SHENANDOAH AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-7672
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11092 ANDERSON ST
Practice Address - Street 2:DEPARTMENT OF DENTAL ANESTHESIA
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92350-1706
Practice Address - Country:US
Practice Address - Phone:909-558-4611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-05
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60052122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist