MEDICARE: DR. LAURISSA MARIE CHAMPION DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	D8555	OR

General Provider Information

NPI Number	:	1568559003
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURISSA MARIE CHAMPION DMD

Provider Business Mailing Address
First Line	:	2115 NE 42ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97213-1321
Country	:	US
Telephone Number	:	503-954-1372
Fax Number	:	503-954-1392

Provider Business Practice Location Address
First Line	:	2115 NE 42ND AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97213-1321
Country	:	US
Telephone Number	:	503-954-1372
Fax Number	:	503-954-1392

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2006
Last Update Date	:	09/15/2008

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