Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 124Q00000X | Dental Hygienist | 2010017946 | MO |
NPI | 1083063655 |
---|---|
Provider Name | Renee Campbell |
First Address | Saint Louis, MO 63112-4265 |
Second Address | Saint Louis, MO 63112-4265 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/06/2016 |
Last Update Date | 06/06/2016 |