Provider Demographics
NPI:1548439417
Name:CHAMPAGNE AND LIGHT, DMDS, LLC
Entity type:Organization
Organization Name:CHAMPAGNE AND LIGHT, DMDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:LIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-351-0072
Mailing Address - Street 1:189 WATERMAN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-4014
Mailing Address - Country:US
Mailing Address - Phone:401-351-0072
Mailing Address - Fax:401-351-0055
Practice Address - Street 1:189 WATERMAN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-4014
Practice Address - Country:US
Practice Address - Phone:401-351-0072
Practice Address - Fax:401-351-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN22161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty