Provider Demographics
NPI:1629089644
Name:CAMPBELL, EDWIN S (DMD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:S
Last Name:CAMPBELL
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:PO BOX 761
Mailing Address - Street 2:
Mailing Address - City:ELBERTON
Mailing Address - State:GA
Mailing Address - Zip Code:30635-0761
Mailing Address - Country:US
Mailing Address - Phone:706-283-1820
Mailing Address - Fax:706-283-1824
Practice Address - Street 1:48 LAUREL DR
Practice Address - Street 2:
Practice Address - City:ELBERTON
Practice Address - State:GA
Practice Address - Zip Code:30635-1842
Practice Address - Country:US
Practice Address - Phone:706-283-1820
Practice Address - Fax:706-283-1824
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA105361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00732531AMedicaid