Provider Demographics
NPI:1457479024
Name:CHAMPION, JEFFREY LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:LEE
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:PO BOX 188
Mailing Address - Street 2:129 N MADISON STREET
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-0188
Mailing Address - Country:US
Mailing Address - Phone:920-324-2561
Mailing Address - Fax:920-324-2561
Practice Address - Street 1:129 N MADISON STREET
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-0188
Practice Address - Country:US
Practice Address - Phone:920-324-2561
Practice Address - Fax:920-324-2561
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3743122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33721600OtherMEDICAL ASSISTANCE