Provider Demographics
NPI:1578605978
Name:JIMMIE LEE JOHNSON DMD PSC
Entity Type:Organization
Organization Name:JIMMIE LEE JOHNSON DMD PSC
Other - Org Name:PSC A SUB S CORPORATION
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-723-3213
Mailing Address - Street 1:PO BOX 175
Mailing Address - Street 2:87 WILDWOOD PLACE
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-1312
Mailing Address - Country:US
Mailing Address - Phone:606-723-3213
Mailing Address - Fax:606-723-3213
Practice Address - Street 1:87 WILDWOOD PLACE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1312
Practice Address - Country:US
Practice Address - Phone:606-723-3213
Practice Address - Fax:606-723-3213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60061637Medicaid