Healthcare Provider Details

I. General information

NPI: 1568559003
Provider Name (Legal Business Name): LAURISSA MARIE CHAMPION DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 NE 42ND AVE
PORTLAND OR
97213-1321
US

IV. Provider business mailing address

2115 NE 42ND AVE
PORTLAND OR
97213-1321
US

V. Phone/Fax

Practice location:
  • Phone: 503-954-1372
  • Fax: 503-954-1392
Mailing address:
  • Phone: 503-954-1372
  • Fax: 503-954-1392

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD8555
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: