Healthcare Provider Details

I. General information

NPI: 1508091679
Provider Name (Legal Business Name): STEPHANIE ANNE CAMPBELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5698W US HIGHWAY 2
MANISTIQUE MI
49854-9116
US

IV. Provider business mailing address

5698W US HIGHWAY 2
MANISTIQUE MI
49854-9116
US

V. Phone/Fax

Practice location:
  • Phone: 906-341-8469
  • Fax: 906-341-1323
Mailing address:
  • Phone: 906-341-8469
  • Fax: 906-341-1323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901019972
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: