Provider Demographics
NPI:1346373651
Name:CAMPBELL, KEVIN THOMAS (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:THOMAS
Last Name:CAMPBELL
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 1:6910 N MAIN ST UNIT 58
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8412
Mailing Address - Country:US
Mailing Address - Phone:574-277-4235
Mailing Address - Fax:574-277-5189
Practice Address - Street 1:6910 N MAIN ST UNIT 58
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8412
Practice Address - Country:US
Practice Address - Phone:574-277-4235
Practice Address - Fax:574-277-5189
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008246A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist