=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144563560
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARISSA EVE CAMPOS D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2013
-----------------------------------------------------
Last Update Date | 10/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3384 COBB PKWY NW STE 130
-----------------------------------------------------
City | ACWORTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30101-8784
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-574-8622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3103 WOODWALK TRCE SE
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30339-8475
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-355-5716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 057724
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN122551
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------