Provider Demographics
NPI:1407963762
Name:JOHNSON, DERRICK V
Entity Type:Individual
Prefix:DR
First Name:DERRICK
Middle Name:V
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:INTEGRATED
Other - Middle Name:
Other - Last Name:DENTISTRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:114 DYER STREET
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653
Mailing Address - Country:US
Mailing Address - Phone:870-580-0950
Mailing Address - Fax:870-580-0951
Practice Address - Street 1:114 DYER STREET
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-580-0950
Practice Address - Fax:870-580-0951
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2015-06-09
Deactivation Date:2012-07-11
Deactivation Code:
Reactivation Date:2015-06-04
Provider Licenses
StateLicense IDTaxonomies
AZ4583122300000X
ARAR3739122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist