MEDICARE: DR. LAURIE TEDDER CAMPBELL DMD

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	1223P0221X	Pediatric Dentistry	10159	NC

General Provider Information

NPI Number	:	1689808164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURIE TEDDER CAMPBELL DMD

Provider Business Mailing Address
First Line	:	7820 BALLANTYNE COMMONS PKWY STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-2889
Country	:	US
Telephone Number	:	704-759-0000
Fax Number	:	704-759-9937

Provider Business Practice Location Address
First Line	:	7820 BALLANTYNE COMMONS PKWY STE 200
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-2889
Country	:	US
Telephone Number	:	704-759-0000
Fax Number	:	704-759-9937

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

Provider Enumeration Date	:	05/12/2009
Last Update Date	:	10/05/2015

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