Healthcare Provider Details

I. General information

NPI: 1275190688
Provider Name (Legal Business Name): SAM BLAKE CAMPBELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S BLISS AVE
TAHLEQUAH OK
74464-2512
US

IV. Provider business mailing address

6718 E 113TH ST S
BIXBY OK
74008-2086
US

V. Phone/Fax

Practice location:
  • Phone: 918-458-3100
  • Fax:
Mailing address:
  • Phone: 918-207-5274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7184
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: