Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0001X | Dental Public Health | 014958 | MO |
NPI | 1427159474 |
---|---|
Provider Name | Dr. Herman Jackson Campbell |
First Address | Kayenta, AZ 86033-0368 |
Second Address | Kayenta, AZ 86033 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 07/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
014958 | PROFESSIONAL LICENSE (01) | MO |
12009731A | PROFESSIONAL LICENSE (01) | IN |
7181 | PROFESSIONAL LICENSE (01) | KS |
DN010881 | PROFESSIONAL LICENSE (01) | GA |