Provider Demographics
NPI:1669642641
Name:DEIRDER M CAMPBELL
Entity Type:Organization
Organization Name:DEIRDER M CAMPBELL
Other - Org Name:COLONIAL DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEIRDRE
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:239-936-7400
Mailing Address - Street 1:4447 CAMINO REAL WAY
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33966-1019
Mailing Address - Country:US
Mailing Address - Phone:239-936-7400
Mailing Address - Fax:239-936-7696
Practice Address - Street 1:4447 CAMINO REAL WAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-1019
Practice Address - Country:US
Practice Address - Phone:239-936-7400
Practice Address - Fax:239-936-7696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62322OtherBC/BS
FL4131731OtherBC/BS