Provider Demographics
NPI:1578771408
Name:JOHNSON DENTISTRY CENTER, P.A.
Entity Type:Organization
Organization Name:JOHNSON DENTISTRY CENTER, P.A.
Other - Org Name:JOHNSON DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:979-774-7500
Mailing Address - Street 1:2752 ROCKCLIFFE LOOP
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3702 COPPERCREST DRIVE
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802
Practice Address - Country:US
Practice Address - Phone:979-774-7500
Practice Address - Fax:979-774-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21064122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSOCIAL SECURITY #
TX21064OtherSTATE LICENSE