Provider Demographics
NPI:1871234898
Name:CHAMPAGNE, CAITLYN (DMD)
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:
Last Name:CHAMPAGNE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CAITLYN
Other - Middle Name:NICOLE
Other - Last Name:BLANCHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01050-9777
Mailing Address - Country:US
Mailing Address - Phone:413-667-3009
Mailing Address - Fax:
Practice Address - Street 1:73 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:MA
Practice Address - Zip Code:01050-9777
Practice Address - Country:US
Practice Address - Phone:413-667-3009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN18596641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program