Provider Demographics
NPI:1578681292
Name:CHAMPAGNE, LARRY L (DMD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:L
Last Name:CHAMPAGNE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5770 FLORIMONT CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-5044
Mailing Address - Country:US
Mailing Address - Phone:775-359-3934
Mailing Address - Fax:775-359-8905
Practice Address - Street 1:925 ROBERTA LN
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-1894
Practice Address - Country:US
Practice Address - Phone:775-359-3934
Practice Address - Fax:775-359-8905
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV8771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice