Provider Demographics
NPI:1033320957
Name:EGBERT, CAMERON JUDD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:JUDD
Last Name:EGBERT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8426 STICKNEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2809
Mailing Address - Country:US
Mailing Address - Phone:801-450-2019
Mailing Address - Fax:
Practice Address - Street 1:642 KIRBY LN STE 101
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-5753
Practice Address - Country:US
Practice Address - Phone:801-798-9500
Practice Address - Fax:801-798-5466
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
UT78353161223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1033320957Medicaid