Provider Demographics
NPI:1518326727
Name:JOHNSON, MONIQUE OLIVIA
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:OLIVIA
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1954 LOWN FARM TRAIL
Mailing Address - Street 2:DEPT OF DENTISTRY-6TH FLOOR
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-8202
Mailing Address - Country:US
Mailing Address - Phone:678-215-3259
Mailing Address - Fax:
Practice Address - Street 1:3752 CASCADE RD SW STE 190
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-2149
Practice Address - Country:US
Practice Address - Phone:678-836-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0155121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice