MEDICARE: DR. TYRUS W CAMPBELL DDS

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	12008966	IN

General Provider Information

NPI Number	:	1750419404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TYRUS W CAMPBELL DDS

Provider Business Mailing Address
First Line	:	931 EAST 86TH STREET
Second Line	:	SUITE 207
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1852
Country	:	US
Telephone Number	:	317-255-0307
Fax Number	:	317-255-0465

Provider Business Practice Location Address
First Line	:	931 E 86TH ST
Second Line	:	SUITE 207
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1860
Country	:	US
Telephone Number	:	317-255-0307
Fax Number	:	317-255-0465

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

Provider Enumeration Date	:	03/02/2007
Last Update Date	:	07/08/2007

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