Healthcare Provider Details

I. General information

NPI: 1316041452
Provider Name (Legal Business Name): CHAMP COY BROWN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 BURNET AVE
CINCINNATI OH
45229-3014
US

IV. Provider business mailing address

3101 BURNET AVE
CINCINNATI OH
45229-3014
US

V. Phone/Fax

Practice location:
  • Phone: 513-357-7289
  • Fax: 513-357-7290
Mailing address:
  • Phone: 513-357-7289
  • Fax: 513-357-7290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30017307
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: