Provider Demographics
NPI:1336867134
Name:CAMACHO, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:CAMACHO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6748 CLARKS NECK RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-7292
Mailing Address - Country:US
Mailing Address - Phone:252-943-1790
Mailing Address - Fax:
Practice Address - Street 1:103 CHURCH ST
Practice Address - Street 2:
Practice Address - City:BROADWAY
Practice Address - State:NC
Practice Address - Zip Code:27505-9394
Practice Address - Country:US
Practice Address - Phone:919-258-9321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13777122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist