Provider Demographics
NPI:1568511582
Name:JOHNSON, STACY DUANE (DDS)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:DUANE
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 1:3056 W STONES CROSSING RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143
Mailing Address - Country:US
Mailing Address - Phone:317-535-7141
Mailing Address - Fax:317-535-7142
Practice Address - Street 1:3056 W STONES CROSSING RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143
Practice Address - Country:US
Practice Address - Phone:317-535-7141
Practice Address - Fax:317-535-7142
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120092391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice