Provider Demographics
NPI:1114157799
Name:JOHNSON, ERICA L (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERICA
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2525 W ILES
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704
Practice Address - Country:US
Practice Address - Phone:217-787-7744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028033122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist