Provider Demographics
NPI:1114398245
Name:JOHNSON, JOHN CAMERON (DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CAMERON
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 1:1313 BROADWAY, SUITE 5
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79401
Mailing Address - Country:US
Mailing Address - Phone:208-871-7273
Mailing Address - Fax:
Practice Address - Street 1:1313 BROADWAY STE 5
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79401-3209
Practice Address - Country:US
Practice Address - Phone:208-871-7273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice