Provider Demographics
NPI:1336353283
Name:CHAMPION, DERRICK RANIER (DDS)
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:RANIER
Last Name:CHAMPION
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:CARRETERA 693 KM 13.7 SUITE 201B
Mailing Address - Street 2:PLAZA DEL MAR SHOPPING CENTER
Mailing Address - City:VEGA ALTA
Mailing Address - State:PR
Mailing Address - Zip Code:00692
Mailing Address - Country:US
Mailing Address - Phone:787-369-7600
Mailing Address - Fax:787-369-7601
Practice Address - Street 1:207 CALLE METIS
Practice Address - Street 2:
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646-4618
Practice Address - Country:US
Practice Address - Phone:787-369-7600
Practice Address - Fax:787-369-7601
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053036122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist