Provider Demographics
NPI:1699427054
Name:CAMPBELL, MARIDITH A
Entity type:Individual
Prefix:
First Name:MARIDITH
Middle Name:A
Last Name:CAMPBELL
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 1:10136 OAKHILL RD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-8846
Mailing Address - Country:US
Mailing Address - Phone:810-841-1706
Mailing Address - Fax:
Practice Address - Street 1:816 JOSLYN AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48340-2919
Practice Address - Country:US
Practice Address - Phone:248-758-1231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI124Q00000X
MI2902012977124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist