Provider Demographics
NPI:1013931252
Name:CHAMPION, GARY L (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:L
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:N10236 LAKE RD
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-9545
Mailing Address - Country:US
Mailing Address - Phone:906-932-5574
Mailing Address - Fax:
Practice Address - Street 1:N10236 LAKE RD
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-9545
Practice Address - Country:US
Practice Address - Phone:906-932-5574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010106481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice