=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164900809
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PATRICIA MICHELLE CAMPBELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2018
-----------------------------------------------------
Last Update Date | 08/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2440 RIVER RD STE 140
-----------------------------------------------------
City | NORCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92860-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-225-1783
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3939 CRANFORD AVE APT 33
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92507-7228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-842-4559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 126800000X
-----------------------------------------------------
Taxonomy Name | Dental Assistant
-----------------------------------------------------
License Number | 79344
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------