Healthcare Provider Details

I. General information

NPI: 1417879578
Provider Name (Legal Business Name): DEREK CHAMPLIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 HOFF ST BLDG 9240
FORT BENNING GA
31905-5645
US

IV. Provider business mailing address

7101 HOFF ST BLDG 9240
FORT BENNING GA
31905-5645
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-2052
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113663
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: