Provider Demographics
NPI:1619299245
Name:JOHNSON, THERESA MARIE (RDH)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 LONG CT
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-4919
Mailing Address - Country:US
Mailing Address - Phone:512-653-6931
Mailing Address - Fax:
Practice Address - Street 1:5900 LONG CT
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78730-4919
Practice Address - Country:US
Practice Address - Phone:512-653-6931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH009098124Q00000X
TX13945124Q00000X
NC8336124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist