Provider Demographics
NPI:1114921491
Name:JOHNSON, KAREN EVANGELINE (DDS, MHS)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:EVANGELINE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS, MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25731
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29224-5731
Mailing Address - Country:US
Mailing Address - Phone:803-606-9011
Mailing Address - Fax:803-630-1529
Practice Address - Street 1:2757 LAUREL ST STE 1
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2037
Practice Address - Country:US
Practice Address - Phone:803-606-9011
Practice Address - Fax:803-630-1529
Is Sole Proprietor?:No
Enumeration Date:2005-06-02
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD117591223P0300X
SC3116/PERIO 4701223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ31163Medicaid