Provider Demographics
NPI:1578587556
Name:CAMPBELL, MARY E (DMD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:E
Other - Last Name:LONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 1988
Mailing Address - Street 2:
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41702-1988
Mailing Address - Country:US
Mailing Address - Phone:606-435-7676
Mailing Address - Fax:606-436-5139
Practice Address - Street 1:101 TOWN AND COUNTRY LN
Practice Address - Street 2:
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9524
Practice Address - Country:US
Practice Address - Phone:606-435-7676
Practice Address - Fax:606-436-5139
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7981122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60-002037Medicaid