Provider Demographics
NPI:1053946525
Name:CHAMPION DENTISTRY, LLC
Entity type:Organization
Organization Name:CHAMPION DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-554-7401
Mailing Address - Street 1:322 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2706
Mailing Address - Country:US
Mailing Address - Phone:615-606-2544
Mailing Address - Fax:888-752-1480
Practice Address - Street 1:322 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2706
Practice Address - Country:US
Practice Address - Phone:615-606-2544
Practice Address - Fax:888-752-1480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-05
Last Update Date:2020-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental