Provider Demographics
NPI:1174509665
Name:JOHNSON, RICHARD LEE (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 CROWN RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76310-1768
Mailing Address - Country:US
Mailing Address - Phone:940-689-8896
Mailing Address - Fax:
Practice Address - Street 1:82 MEDICAL GROUP/CREDENTIALS
Practice Address - Street 2:149 HART STREET
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311-3482
Practice Address - Country:US
Practice Address - Phone:940-676-2003
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000053481223S0112X
TNMD0000035690204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXVAD000Medicare UPIN