Provider Demographics
NPI:1437163599
Name:JOHNSON, CHARLES CHAD (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:CHAD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:C.
Other - Middle Name:CHAD
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:2907 E JOYCE BLVD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5011
Mailing Address - Country:US
Mailing Address - Phone:479-445-6688
Mailing Address - Fax:
Practice Address - Street 1:2907 E JOYCE BLVD
Practice Address - Street 2:SUITE 12
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5011
Practice Address - Country:US
Practice Address - Phone:479-445-6688
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR33771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X003OtherBLUE CROSS PROVIDER NUMBE
PA1397170OtherUNITED CONCORDIA NUMER