Provider Demographics
NPI:1962610071
Name:CAMPBELL, FITZROY GEORGE (DMD)
Entity type:Individual
Prefix:DR
First Name:FITZROY
Middle Name:GEORGE
Last Name:CAMPBELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 COZINE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11207-9237
Mailing Address - Country:US
Mailing Address - Phone:718-927-2530
Mailing Address - Fax:718-927-2381
Practice Address - Street 1:405 COZINE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207-9237
Practice Address - Country:US
Practice Address - Phone:718-927-2530
Practice Address - Fax:718-927-2381
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY045820-11223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020713873Medicaid