Healthcare Provider Details

I. General information

NPI: 1003079500
Provider Name (Legal Business Name): AARON GLENN CAMPBELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 06/30/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 W PORT PLZ STE 367
SAINT LOUIS MO
63146-3124
US

IV. Provider business mailing address

77 W PORT PLZ STE 367
SAINT LOUIS MO
63146-3124
US

V. Phone/Fax

Practice location:
  • Phone: 314-434-4676
  • Fax: 314-434-6806
Mailing address:
  • Phone: 314-434-4676
  • Fax: 314-434-6806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2008015942
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2008015942
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: