Healthcare Provider Details

I. General information

NPI: 1558276733
Provider Name (Legal Business Name): DASIANA CHAMPAGNE
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24065 BIGGAR LN
COVELO CA
95428
US

IV. Provider business mailing address

24065 BIGGAR LN
COVELO CA
95428
US

V. Phone/Fax

Practice location:
  • Phone: 707-983-6181
  • Fax:
Mailing address:
  • Phone: 707-983-6181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number36410
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: