Provider Demographics
NPI:1124031695
Name:JOHNSON, JODI BROOKE (DMD)
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:BROOKE
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 1:9775 SAINT CHARLES ROCK RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63114-2635
Mailing Address - Country:US
Mailing Address - Phone:314-427-7400
Mailing Address - Fax:
Practice Address - Street 1:9775 SAINT CHARLES ROCK RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63114-2635
Practice Address - Country:US
Practice Address - Phone:314-427-7400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20050175061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO4013924202Medicaid