Provider Demographics
NPI:1710657630
Name:CAMPBELL DENTAL GROUP, PC
Entity Type:Organization
Organization Name:CAMPBELL DENTAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:503-283-2553
Mailing Address - Street 1:17065 SW KINGLET DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-8195
Mailing Address - Country:US
Mailing Address - Phone:503-313-5874
Mailing Address - Fax:
Practice Address - Street 1:5610 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97203-4224
Practice Address - Country:US
Practice Address - Phone:503-283-2553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-14
Last Update Date:2021-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental