Provider Demographics
NPI:1497083471
Name:JOHNSON, LEAH JENNINGS (DMD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:JENNINGS
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2732 E LONDONDERRY DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-2796
Mailing Address - Country:US
Mailing Address - Phone:502-645-2044
Mailing Address - Fax:
Practice Address - Street 1:614 E EMMA AVE
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-4634
Practice Address - Country:US
Practice Address - Phone:479-751-7417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AR38141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program