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General NPI Number Information
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NPI Number | 1326613787
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Entity Type | Individual
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Provider Name | JACKIE CALLAWAY-CAMPBELL DT
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Gender | Female
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Dates
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Enumeration Date | 05/26/2021
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Last Update Date | 05/26/2021
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Provider Practice Location Address
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Address Line | 405 BABCOCK BLVD E STE 130
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City | DELANO
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State | MN
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Zip | 55328-9144
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Country | US
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Telephone | 763-276-1410
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Fax | 763-276-1411
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Provider Business Mailing Address
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Address Line | 414 7TH ST SE APT 103
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City | MINNEAPOLIS
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State | MN
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Zip | 55414-1272
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Country | US
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Telephone | 302-598-3863
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 125J00000X
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Taxonomy Name | Dental Therapist
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License Number | DT136
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License Number State | MN
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