Provider Demographics
NPI:1164599452
Name:KEITH D JOHNSON DDS PC
Entity Type:Organization
Organization Name:KEITH D JOHNSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-781-7571
Mailing Address - Street 1:26 S VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068
Mailing Address - Country:US
Mailing Address - Phone:816-781-7571
Mailing Address - Fax:816-781-7933
Practice Address - Street 1:26 S VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068
Practice Address - Country:US
Practice Address - Phone:816-781-7571
Practice Address - Fax:816-781-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO14182122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty