Provider Demographics
NPI:1497836704
Name:JOHNSON, KENNETH WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:WAYNE
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 1:1407 MITTS DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-2215
Mailing Address - Country:US
Mailing Address - Phone:662-840-8540
Mailing Address - Fax:662-840-0629
Practice Address - Street 1:704 HILLCREST
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804
Practice Address - Country:US
Practice Address - Phone:662-840-8540
Practice Address - Fax:662-840-0629
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPEDO297961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry