Provider Demographics
NPI:1265918312
Name:CHAMPAGNE DENTAL CORP
Entity type:Organization
Organization Name:CHAMPAGNE DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:727-251-1907
Mailing Address - Street 1:2385 NW EXECUTIVE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-8510
Mailing Address - Country:US
Mailing Address - Phone:727-251-1907
Mailing Address - Fax:727-535-1185
Practice Address - Street 1:1330 S BELCHER RD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33764-3713
Practice Address - Country:US
Practice Address - Phone:727-535-3233
Practice Address - Fax:727-535-1185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19345122300000X
FLDN19494122300000X
FLDN11998122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1649568767OtherCATHERINE DE LA TORRE DMD
FL1063545242OtherGEORGE HITZEL DDS
FL1164710976OtherLINDSEY REZNIK DMD