Provider Demographics
NPI:1902013089
Name:DR. CAMPBELL'S CENTURY DENTAL OFFICE, DR. CAMPBELL, DDS, INC.
Entity Type:Organization
Organization Name:DR. CAMPBELL'S CENTURY DENTAL OFFICE, DR. CAMPBELL, DDS, INC.
Other - Org Name:DR. CAMPBELL'S CENTURY DENTAL OFFICE,
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-585-9544
Mailing Address - Street 1:1955 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ALTADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91001-3037
Mailing Address - Country:US
Mailing Address - Phone:626-585-9544
Mailing Address - Fax:626-449-4932
Practice Address - Street 1:1955 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ALTADENA
Practice Address - State:CA
Practice Address - Zip Code:91001-3037
Practice Address - Country:US
Practice Address - Phone:626-585-9544
Practice Address - Fax:626-449-4932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty