Provider Demographics
NPI:1417006677
Name:JOHNSON, SAMUEL L (DDS)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:L
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 1:740 HILLCREST RD STE 2B
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-4021
Mailing Address - Country:US
Mailing Address - Phone:251-639-0911
Mailing Address - Fax:251-633-7889
Practice Address - Street 1:740 HILLCREST RD STE 2B
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4021
Practice Address - Country:US
Practice Address - Phone:251-639-0911
Practice Address - Fax:251-633-7889
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL40491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL92365OtherBLUE CROSS PROVIDER #
AL05645Medicare UPIN