MEDICARE: MITRA ANN CAMPBELL

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	122300000X	Dentist	019027587	IL
2	1223G0001X	General Practice Dentistry	16626	FL

General Provider Information

NPI Number	:	1356491138
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITRA ANN CAMPBELL

Provider Business Mailing Address
First Line	:	4144 N ARMENIA AVE
Second Line	:	SUITE 260
City	:	TAMPA
State	:	FL
Zip	:	33607-6400
Country	:	US
Telephone Number	:	813-870-0480
Fax Number	:	813-870-0482

Provider Business Practice Location Address
First Line	:	4144 N ARMENIA AVE
Second Line	:	SUITE 260
City	:	TAMPA
State	:	FL
Zip	:	33607-6400
Country	:	US
Telephone Number	:	813-870-0480
Fax Number	:	813-870-0482

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	04/11/2013

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Directions to “ MITRA ANN CAMPBELL ” Practice Location

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