Provider Demographics
NPI:1215332374
Name:JASON CHAMPAGNE V, LLC
Entity type:Organization
Organization Name:JASON CHAMPAGNE V, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARIANN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:CHAMPAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:775-359-3934
Mailing Address - Street 1:PO BOX 2070
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89432-2070
Mailing Address - Country:US
Mailing Address - Phone:775-359-3934
Mailing Address - Fax:775-359-4034
Practice Address - Street 1:1125 AVENUE OF THE OAKS UNIT 161
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89431-4913
Practice Address - Country:US
Practice Address - Phone:775-335-3199
Practice Address - Fax:775-870-1632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-30
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV40491223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty