Healthcare Provider Details

I. General information

NPI: 1164900809
Provider Name (Legal Business Name): PATRICIA MICHELLE CAMPBELL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 08/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 RIVER RD STE 140
NORCO CA
92860-2402
US

IV. Provider business mailing address

3939 CRANFORD AVE APT 33
RIVERSIDE CA
92507-7228
US

V. Phone/Fax

Practice location:
  • Phone: 951-225-1783
  • Fax:
Mailing address:
  • Phone: 951-842-4559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number79344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: