Provider Demographics
NPI:1134467731
Name:JOHNSON, JUSTIN WESLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:WESLEY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11201 HUGUENOT ROAD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235
Mailing Address - Country:US
Mailing Address - Phone:804-417-7203
Mailing Address - Fax:
Practice Address - Street 1:11201 HUGUENOT ROAD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235
Practice Address - Country:US
Practice Address - Phone:804-417-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-17
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist