Provider Demographics
NPI:1083839708
Name:JOHNSON, SCOTT RAYMOND (DDS)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:RAYMOND
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 1:1725 STARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-1445
Mailing Address - Country:US
Mailing Address - Phone:706-221-6040
Mailing Address - Fax:
Practice Address - Street 1:2712 HIGHWAY 34 E
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265
Practice Address - Country:US
Practice Address - Phone:770-304-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice