Provider Demographics
NPI:1033786033
Name:CAMPBELL, DEAN PRESTON (LAC)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:PRESTON
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-3010
Mailing Address - Country:US
Mailing Address - Phone:208-616-1040
Mailing Address - Fax:
Practice Address - Street 1:5622 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-3010
Practice Address - Country:US
Practice Address - Phone:208-616-1040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDACU-332171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist