Healthcare Provider Details

I. General information

NPI: 1538835871
Provider Name (Legal Business Name): JASON CHAMPAGNE II PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 W MOANA LN STE 6
RENO NV
89509-4959
US

IV. Provider business mailing address

601 W MOANA LN STE 6
RENO NV
89509-4959
US

V. Phone/Fax

Practice location:
  • Phone: 775-636-9939
  • Fax:
Mailing address:
  • Phone: 775-583-7755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X2210X
TaxonomyOrofacial Pain Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. JASON CHAMPAGNE
Title or Position: OWNER
Credential: DDS
Phone: 775-636-9939