Provider Demographics
NPI:1598975971
Name:JOHNSON, SHANNON POLLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:POLLY
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 1:2913 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2106
Mailing Address - Country:US
Mailing Address - Phone:502-957-9390
Mailing Address - Fax:
Practice Address - Street 1:9510 ORMSBY STATION RD STE 203
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4083
Practice Address - Country:US
Practice Address - Phone:028-050-5005
Practice Address - Fax:502-771-6041
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 17245122300000X
KY7939122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist