Provider Demographics
NPI:1487035457
Name:JOHNSON, PHILLIP ISAAC (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ISAAC
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 1:914 PHEASANT DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-6790
Mailing Address - Country:US
Mailing Address - Phone:432-312-8453
Mailing Address - Fax:
Practice Address - Street 1:914 PHEASANT DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-6790
Practice Address - Country:US
Practice Address - Phone:432-312-8453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-15
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX310081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice