1578587556 NPI number — MARY E. CAMPBELL DMD

Table of content: MARY E. CAMPBELL DMD (NPI 1578587556)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578587556 NPI number — MARY E. CAMPBELL DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMPBELL
Provider First Name:
MARY
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LONG
Provider Other First Name:
MARY
Provider Other Middle Name:
E.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578587556
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1988
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZARD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41702-1988
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-435-7676
Provider Business Mailing Address Fax Number:
606-436-5139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 TOWN AND COUNTRY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZARD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41701-9524
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-435-7676
Provider Business Practice Location Address Fax Number:
606-436-5139
Provider Enumeration Date:
07/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  7981 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 60-002037 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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