Provider Demographics
NPI:1104044312
Name:CHAMPION, RONALD LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:LYNN
Last Name:CHAMPION
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4101 TULLY RD STE 401
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-8982
Mailing Address - Country:US
Mailing Address - Phone:209-575-5888
Mailing Address - Fax:209-575-5898
Practice Address - Street 1:4101 TULLY RD STE 401
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-8982
Practice Address - Country:US
Practice Address - Phone:209-575-5888
Practice Address - Fax:209-575-5898
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA234891223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics