Provider Demographics
NPI:1386026003
Name:JOHNSON, MATTHEW S (DMD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N HILLSBOROUGH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-2411
Mailing Address - Country:US
Mailing Address - Phone:803-386-5244
Mailing Address - Fax:
Practice Address - Street 1:3732 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2983
Practice Address - Country:US
Practice Address - Phone:919-471-6622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103341223G0001X
SC85581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice