Provider Demographics
NPI:1750419404
Name:CAMPBELL, TYRUS W (DDS)
Entity type:Individual
Prefix:DR
First Name:TYRUS
Middle Name:W
Last Name:CAMPBELL
Suffix:
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 1:931 EAST 86TH STREET
Mailing Address - Street 2:SUITE 207
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1852
Mailing Address - Country:US
Mailing Address - Phone:317-255-0307
Mailing Address - Fax:317-255-0465
Practice Address - Street 1:931 E 86TH ST
Practice Address - Street 2:SUITE 207
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1860
Practice Address - Country:US
Practice Address - Phone:317-255-0307
Practice Address - Fax:317-255-0465
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008966122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist