Provider Demographics
NPI:1659594497
Name:CAMPBELL, LISA MICHELE (DDS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:MICHELE
Other - Last Name:HAMILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:950 COUNTY ROAD 17A W
Mailing Address - Street 2:
Mailing Address - City:AVON PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33825-2164
Mailing Address - Country:US
Mailing Address - Phone:863-452-3000
Mailing Address - Fax:863-452-3069
Practice Address - Street 1:950 COUNTY ROAD 17A W
Practice Address - Street 2:
Practice Address - City:AVON PARK
Practice Address - State:FL
Practice Address - Zip Code:33825-2164
Practice Address - Country:US
Practice Address - Phone:863-452-3000
Practice Address - Fax:863-452-3069
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21248122300000X
OH19960122300000X
FLDN 192061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7285021OtherPROVIDER IDENTIFICATION #
FLDN 19206OtherFLORIDA LICENSE
FL003001500Medicaid
FC2300678OtherDEA
FL003001500Medicaid