Provider Demographics
NPI:1194257022
Name:CAMPBELL, JORDAN (DDS)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 S LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-6625
Mailing Address - Country:US
Mailing Address - Phone:801-682-9739
Mailing Address - Fax:
Practice Address - Street 1:3185 CLEARWATER DR STE B
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7119
Practice Address - Country:US
Practice Address - Phone:928-775-2545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0112901223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery