Healthcare Provider Details

I. General information

NPI: 1194768630
Provider Name (Legal Business Name): JOHN H CAMPBELL IV DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3435 MAIN ST, 119 SQUIRE HALL
BUFFALO NY
14214
US

IV. Provider business mailing address

3435 MAIN ST 119 SQUIRE HALL
BUFFALO NY
14214-3001
US

V. Phone/Fax

Practice location:
  • Phone: 716-829-6637
  • Fax: 716-829-3019
Mailing address:
  • Phone: 716-829-6637
  • Fax: 716-829-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number036022
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0360221
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: