Provider Demographics
NPI:1457645384
Name:CAMPBELL, KANISHA S (DMD)
Entity Type:Individual
Prefix:DR
First Name:KANISHA
Middle Name:S
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3565 ROUTE 611 FL 2
Mailing Address - Street 2:
Mailing Address - City:BARTONSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18321-7800
Mailing Address - Country:US
Mailing Address - Phone:570-629-1142
Mailing Address - Fax:
Practice Address - Street 1:3565 ROUTE 611 FL 2
Practice Address - Street 2:
Practice Address - City:BARTONSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18321-7800
Practice Address - Country:US
Practice Address - Phone:570-629-1142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0425731223P0221X
TX307261223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program