=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326692930
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAKENSEY CAMPBELL DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2019
-----------------------------------------------------
Last Update Date | 07/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 SUNSET DR # A5
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-283-4442
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 426 HUNTERS CROSSING LN
-----------------------------------------------------
City | KINGSPORT
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37664-5453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-276-8489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 11090
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------