Provider Demographics
NPI:1013558519
Name:JOHNSON, CONNOR SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:CONNOR
Middle Name:SCOTT
Last Name:JOHNSON
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 1:4509 ARGONNE CT
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-6443
Mailing Address - Country:US
Mailing Address - Phone:804-252-1976
Mailing Address - Fax:
Practice Address - Street 1:7476 WATERSIDE LOOP RD STE 100
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-7680
Practice Address - Country:US
Practice Address - Phone:704-820-9797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-05
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC95941223G0001X
390200000X
NC125911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program