Healthcare Provider Details

I. General information

NPI: 1245363050
Provider Name (Legal Business Name): KEITH E CAMPBELL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 SAYBROOK RD
HIGGANUM CT
06441-4100
US

IV. Provider business mailing address

PO BOX 336
HIGGANUM CT
06441-0336
US

V. Phone/Fax

Practice location:
  • Phone: 860-345-2282
  • Fax:
Mailing address:
  • Phone: 860-345-2282
  • Fax: 860-345-4908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number007882
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: