Basic Information
| Provider Information | |||||||||
| NPI: | 1659455913 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CAMPBELL | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | IAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 5809 N 32ND ST | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740145119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099396364 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6333 E SKELLY DR | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741356106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186644224 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D10407 | OR | N | Dental Providers | Dentist | 1223G0001X | 4747 | OK | N | Dental Providers | Dentist | General Practice | 1223G0001X | DE8341 | WA | N | Dental Providers | Dentist | General Practice | 175T00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 8341 | 01 | WA | STATE LICENSE NUMBER | OTHER | D10407 | 01 | OR | OREGON DENTAL BOARD | OTHER | 4747 | 01 | OK | STATE DENTAL LICENSE | OTHER |