MEDICARE: DR. CAMPBELL DDS, INC.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G91343	OTHER	CA	G91343-01 TO 10 MEDICAL

General Provider Information

NPI Number	:	1194724070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. CAMPBELL DDS, INC.

Provider Business Mailing Address
First Line	:	1955 LAKE AVE
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-3037
Country	:	US
Telephone Number	:	626-585-9544
Fax Number	:	626-449-4932

Provider Business Practice Location Address
First Line	:	1955 LAKE AVE
Second Line	:
City	:	ALTADENA
State	:	CA
Zip	:	91001-3037
Country	:	US
Telephone Number	:	626-585-9544
Fax Number	:	626-449-4932

Authorized Official
Title or Position	:	CEO
Name	:	DR. DAVID STUART CAMPBELL
Credential	:	D.D.S.
Telephone Number	:	626-585-9544

Provider Enumeration Date	:	07/21/2005
Last Update Date	:	07/21/2022

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