Provider Demographics
NPI:1407019243
Name:CHAMPION, TINA MICHELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MICHELL
Last Name:CHAMPION
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TINA
Other - Middle Name:MICHELL
Other - Last Name:CHAMPION-HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1547 BELL FLOWER CT
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30088-3707
Mailing Address - Country:US
Mailing Address - Phone:708-218-3296
Mailing Address - Fax:708-575-0401
Practice Address - Street 1:1980M N COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-2020
Practice Address - Country:US
Practice Address - Phone:478-387-7015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-02
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190257541223G0001X
GADN0150801223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice