Provider Demographics
NPI:1437247889
Name:LARRY A JOHNSON DDS PC
Entity Type:Organization
Organization Name:LARRY A JOHNSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:508-347-2673
Mailing Address - Street 1:69 HALL ROAD
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:01566
Mailing Address - Country:US
Mailing Address - Phone:508-347-2673
Mailing Address - Fax:508-347-5085
Practice Address - Street 1:69 HALL ROAD
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01566
Practice Address - Country:US
Practice Address - Phone:508-347-2673
Practice Address - Fax:508-347-5085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA123561223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty