Provider Demographics
NPI:1477907061
Name:CAMP, NATHANIEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:CAMP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 COMMUNITY SQUARE BLVD
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1731
Mailing Address - Country:US
Mailing Address - Phone:770-459-1663
Mailing Address - Fax:
Practice Address - Street 1:50 COMMUNITY SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1731
Practice Address - Country:US
Practice Address - Phone:770-459-1663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6333-C11223G0001X
390200000X
GADN0152781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program