Provider Demographics
NPI:1700858701
Name:CAMPBELL, SAMUEL JR (DDS)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:CAMPBELL
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7532 SAUTERNE CT
Mailing Address - Street 2:
Mailing Address - City:INDEANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46278
Mailing Address - Country:US
Mailing Address - Phone:317-872-5282
Mailing Address - Fax:317-875-7275
Practice Address - Street 1:8240 NAAB ZAL
Practice Address - Street 2:STE 355
Practice Address - City:INDEANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-876-1095
Practice Address - Fax:317-875-7275
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007499A122300000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000244574OtherBLUE SHIELD ID