Healthcare Provider Details

I. General information

NPI: 1669642641
Provider Name (Legal Business Name): DEIRDER M CAMPBELL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4447 CAMINO REAL WAY
FORT MYERS FL
33966-1019
US

IV. Provider business mailing address

4447 CAMINO REAL WAY
FORT MYERS FL
33966-1019
US

V. Phone/Fax

Practice location:
  • Phone: 239-936-7400
  • Fax: 239-936-7696
Mailing address:
  • Phone: 239-936-7400
  • Fax: 239-936-7696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN16533
License Number StateFL

VIII. Authorized Official

Name: DR. DEIRDRE M CAMPBELL
Title or Position: OWNER
Credential: D.M.D.
Phone: 239-936-7400