Provider Demographics
NPI:1467903393
Name:CAMPOS, VANESSA
Entity Type:Individual
Prefix:MISS
First Name:VANESSA
Middle Name:
Last Name:CAMPOS
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 1:1752 N TAFT AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:IL
Mailing Address - Zip Code:60163-1555
Mailing Address - Country:US
Mailing Address - Phone:708-449-8683
Mailing Address - Fax:
Practice Address - Street 1:1752 N TAFT AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:IL
Practice Address - Zip Code:60163-1555
Practice Address - Country:US
Practice Address - Phone:708-449-8683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL020014796124Q00000X
IN13007774A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist