Provider Demographics
NPI:1356491138
Name:CAMPBELL, MITRA ANN
Entity Type:Individual
Prefix:
First Name:MITRA
Middle Name:ANN
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4144 N ARMENIA AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6400
Mailing Address - Country:US
Mailing Address - Phone:813-870-0480
Mailing Address - Fax:813-870-0482
Practice Address - Street 1:4144 N ARMENIA AVE
Practice Address - Street 2:SUITE 260
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6400
Practice Address - Country:US
Practice Address - Phone:813-870-0480
Practice Address - Fax:813-870-0482
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027587122300000X
FL166261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist