Healthcare Provider Details

I. General information

NPI: 1104708122
Provider Name (Legal Business Name): ANDREA CAMPOLI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 LANDMARK DR STE 126
GLEN BURNIE MD
21061-4486
US

IV. Provider business mailing address

804 LANDMARK DR STE 126
GLEN BURNIE MD
21061-4486
US

V. Phone/Fax

Practice location:
  • Phone: 410-761-9180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number16893
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: