Provider Demographics
NPI:1770954083
Name:CAMPBELL, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8472 SIMMOND ST
Mailing Address - Street 2:
Mailing Address - City:FORT MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755-5700
Mailing Address - Country:US
Mailing Address - Phone:301-677-6078
Mailing Address - Fax:
Practice Address - Street 1:8472 SIMMOND ST
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-5700
Practice Address - Country:US
Practice Address - Phone:301-677-6078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014150281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice