Provider Demographics
NPI:1316042237
Name:JOHNSON, TIMOTHY TERELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:TERELL
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 1:512 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-4254
Mailing Address - Country:US
Mailing Address - Phone:601-855-5885
Mailing Address - Fax:601-855-2833
Practice Address - Street 1:512 W FULTON ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MS
Practice Address - Zip Code:39046-4254
Practice Address - Country:US
Practice Address - Phone:601-855-5885
Practice Address - Fax:601-855-2833
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3108-99122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0060251Medicaid