Provider Demographics
NPI:1245215508
Name:CHAMPION, ALLEN F (DDS)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:F
Last Name:CHAMPION
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 1:909 WALNUT STREET
Mailing Address - Street 2:300 COB
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:215-955-6215
Mailing Address - Fax:215-923-9189
Practice Address - Street 1:909 WALNUT STREET
Practice Address - Street 2:300 COB
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-6215
Practice Address - Fax:215-923-9189
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2019-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0371061223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0270113Medicaid
PA1026152500001Medicaid
NJ0270113Medicaid