Healthcare Provider Details

I. General information

NPI: 1467903393
Provider Name (Legal Business Name): MISS VANESSA CAMPOS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2016
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 N TAFT AVE
BERKELEY IL
60163-1555
US

IV. Provider business mailing address

1752 N TAFT AVE
BERKELEY IL
60163-1555
US

V. Phone/Fax

Practice location:
  • Phone: 708-449-8683
  • Fax:
Mailing address:
  • Phone: 708-449-8683
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number020014796
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number13007774A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: