Healthcare Provider Details

I. General information

NPI: 1508863523
Provider Name (Legal Business Name): DOUGLAS L. CAMPBELL DDS, MS, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N KENDRICK ST SUITE 300
FLAGSTAFF AZ
86001-1586
US

IV. Provider business mailing address

750 N KENDRICK ST SUITE 300
FLAGSTAFF AZ
86001-1586
US

V. Phone/Fax

Practice location:
  • Phone: 928-774-2238
  • Fax:
Mailing address:
  • Phone: 928-774-2238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD4934
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: