Provider Demographics
NPI:1093964900
Name:JOHNSON, JACOB ADAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ADAM
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 1:2101 BRADLEY DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-6868
Mailing Address - Country:US
Mailing Address - Phone:480-207-9709
Mailing Address - Fax:
Practice Address - Street 1:3050 SYCAMORE SCHOOL RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76133
Practice Address - Country:US
Practice Address - Phone:817-370-0021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-16
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD77481223P0221X
TX346301223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry