Provider Demographics
NPI:1346206869
Name:JOHNSON, STACY CEDRIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:CEDRIC
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 1:2727 N HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-2911
Mailing Address - Country:US
Mailing Address - Phone:317-299-0706
Mailing Address - Fax:317-328-4859
Practice Address - Street 1:2727 N HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-2911
Practice Address - Country:US
Practice Address - Phone:317-299-0706
Practice Address - Fax:317-328-4859
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120101631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice