Provider Demographics
NPI:1578618542
Name:CAMPBELL, JACK PARKER (DMD P,A,)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:PARKER
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DMD P,A,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 WELLS RD STE 19
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-2374
Mailing Address - Country:US
Mailing Address - Phone:904-264-9096
Mailing Address - Fax:904-264-4250
Practice Address - Street 1:1700 WELLS RD STE 19
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-2374
Practice Address - Country:US
Practice Address - Phone:904-264-9096
Practice Address - Fax:904-264-4250
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2010-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN86721223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics