Provider Demographics
NPI:1164507521
Name:JOHNSON, WILLIAM RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RICHARD
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 1:420 S CRAIN HWY
Mailing Address - Street 2:STE 5
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3657
Mailing Address - Country:US
Mailing Address - Phone:410-766-6464
Mailing Address - Fax:410-787-2577
Practice Address - Street 1:420 S CRAIN HWY
Practice Address - Street 2:STE 5
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3657
Practice Address - Country:US
Practice Address - Phone:410-766-6464
Practice Address - Fax:410-787-2577
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD59111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice