MEDICARE: AARON G CAMPBELL PERIODONTICS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1225715303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AARON G CAMPBELL PERIODONTICS LLC

Provider Business Mailing Address
First Line	:	77 W PORT PLZ STE 367
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3124
Country	:	US
Telephone Number	:	314-434-4676
Fax Number	:	314-434-6806

Provider Business Practice Location Address
First Line	:	77 W PORT PLZ STE 367
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63146-3124
Country	:	US
Telephone Number	:	314-434-4676
Fax Number	:	314-434-6806

Authorized Official
Title or Position	:	OWNER
Name	:	AARON GLENN CAMPBELL
Credential	:	DDS, MS
Telephone Number	:	314-434-4676

Provider Enumeration Date	:	06/30/2023
Last Update Date	:	06/30/2023

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