Provider Demographics
NPI:1649408576
Name:JASON C. CAMPBELL DDS.
Entity Type:Organization
Organization Name:JASON C. CAMPBELL DDS.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIVETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-776-1208
Mailing Address - Street 1:139 WHIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-1705
Mailing Address - Country:US
Mailing Address - Phone:928-776-1208
Mailing Address - Fax:928-541-9648
Practice Address - Street 1:139 WHIPPLE ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1705
Practice Address - Country:US
Practice Address - Phone:928-776-1208
Practice Address - Fax:928-541-9648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6176122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty