Basic Information
Provider Information | |||||||||
NPI: | 1558573212 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CAMPBELL | ||||||||
FirstName: | AMY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 780 CARIBOU DR W | ||||||||
Address2: |   | ||||||||
City: | MONUMENT | ||||||||
State: | CO | ||||||||
PostalCode: | 801328570 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2152801760 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1055 E STEWART AVE BLDG 2018 | ||||||||
Address2: |   | ||||||||
City: | PETERSON AFB | ||||||||
State: | CO | ||||||||
PostalCode: | 809142900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7195561333 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2007 | ||||||||
LastUpdateDate: | 03/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/10/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0300X | 27854 | TX | N |   | Dental Providers | Dentist | Periodontics | 1223P0300X | DS036931 | PA | N |   | Dental Providers | Dentist | Periodontics | 1223P0300X | DEN.00204534 | CO | Y |   | Dental Providers | Dentist | Periodontics |
No ID Information.