Provider Demographics
NPI:1194768630
Name:CAMPBELL, JOHN H IV (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:CAMPBELL
Suffix:IV
Gender:M
Credentials:DDS, MS
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Mailing Address - Street 1:3435 MAIN ST
Mailing Address - Street 2:119 SQUIRE HALL
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-3001
Mailing Address - Country:US
Mailing Address - Phone:716-829-6637
Mailing Address - Fax:716-829-2047
Practice Address - Street 1:3435 MAIN ST, 119 SQUIRE HALL
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214
Practice Address - Country:US
Practice Address - Phone:716-829-6637
Practice Address - Fax:716-829-3019
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY036022204E00000X
NY03602211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01151064Medicaid
NYU21365Medicare UPIN