Provider Demographics
NPI:1558543066
Name:JOHNSON, LAURIS WALLACE (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURIS
Middle Name:WALLACE
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 1:3621 VININGS SLOPE SE
Mailing Address - Street 2:3309
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4107
Mailing Address - Country:US
Mailing Address - Phone:770-235-7618
Mailing Address - Fax:
Practice Address - Street 1:3621 VININGS SLOPE SE
Practice Address - Street 2:3309
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-4107
Practice Address - Country:US
Practice Address - Phone:770-235-7618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN168761223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics