Provider Demographics
NPI:1760852867
Name:CAMPER, MARISA LEE (RDH BS)
Entity Type:Individual
Prefix:MRS
First Name:MARISA
Middle Name:LEE
Last Name:CAMPER
Suffix:
Gender:F
Credentials:RDH BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 W ORMAN AVE
Mailing Address - Street 2:DENTAL HYGIENE PROGRAM
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-1430
Mailing Address - Country:US
Mailing Address - Phone:719-549-3269
Mailing Address - Fax:
Practice Address - Street 1:900 W ORMAN AVE
Practice Address - Street 2:DENTAL HYGIENE PROGRAM
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-1430
Practice Address - Country:US
Practice Address - Phone:719-549-3269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO000904870124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist