Provider Demographics
NPI:1790978849
Name:JASON M. CAMPBELL DDS INC.
Entity Type:Organization
Organization Name:JASON M. CAMPBELL DDS INC.
Other - Org Name:GWINNETT PLACE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:770-476-4140
Mailing Address - Street 1:2100 PLEASANT HILL RD
Mailing Address - Street 2:SUITE 366
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4701
Mailing Address - Country:US
Mailing Address - Phone:770-476-4140
Mailing Address - Fax:
Practice Address - Street 1:2100 PLEASANT HILL RD
Practice Address - Street 2:SUITE 366
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4701
Practice Address - Country:US
Practice Address - Phone:770-476-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty