Provider Demographics
NPI:1164707972
Name:ALICE J JOHNSON, DDS, PA
Entity Type:Organization
Organization Name:ALICE J JOHNSON, DDS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-452-2195
Mailing Address - Street 1:5802 BERKAMN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-2625
Mailing Address - Country:US
Mailing Address - Phone:512-452-2195
Mailing Address - Fax:512-452-1871
Practice Address - Street 1:5802 BERKAMN DR
Practice Address - Street 2:SUITE B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-2625
Practice Address - Country:US
Practice Address - Phone:512-452-2195
Practice Address - Fax:512-452-1871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17654261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX19922049741OtherNPI