Provider Demographics
NPI:1679312995
Name:CAMPBELL, BARON (DDS)
Entity type:Individual
Prefix:
First Name:BARON
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 1:16722 W MUD VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-1039
Mailing Address - Country:US
Mailing Address - Phone:918-457-6335
Mailing Address - Fax:
Practice Address - Street 1:320 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5409
Practice Address - Country:US
Practice Address - Phone:918-423-0091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK78411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice