Provider Demographics
NPI:1841458932
Name:CHAMPION, CHARLES JR
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:
Last Name:CHAMPION
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 N 63RD ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19151-3208
Mailing Address - Country:US
Mailing Address - Phone:215-473-4717
Mailing Address - Fax:215-877-2022
Practice Address - Street 1:1170 N 63RD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19151-3208
Practice Address - Country:US
Practice Address - Phone:215-473-4717
Practice Address - Fax:215-877-2022
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO26682L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist