Provider Demographics
NPI:1063774784
Name:LAURISSA CHAMPION DMD LLC
Entity type:Organization
Organization Name:LAURISSA CHAMPION DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURISSA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHAMPION
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-954-1372
Mailing Address - Street 1:2824 NE WASCO ST
Mailing Address - Street 2:SUITE 230
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1772
Mailing Address - Country:US
Mailing Address - Phone:503-954-1372
Mailing Address - Fax:503-954-1392
Practice Address - Street 1:2824 NE WASCO ST
Practice Address - Street 2:SUITE 230
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1772
Practice Address - Country:US
Practice Address - Phone:503-954-1372
Practice Address - Fax:503-954-1392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD85551223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty