Provider Demographics
NPI:1356472765
Name:JOHNSON, LARRY (DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
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:PO BOX 3487
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61826-3487
Mailing Address - Country:US
Mailing Address - Phone:217-352-9494
Mailing Address - Fax:217-352-7971
Practice Address - Street 1:919 W KIRBY AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821-5121
Practice Address - Country:US
Practice Address - Phone:217-352-9494
Practice Address - Fax:217-352-7971
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice