Provider Demographics
NPI:1619586773
Name:STACY D JOHNSON DDS PC
Entity Type:Organization
Organization Name:STACY D JOHNSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STACY
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-431-0837
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:46143-6484
Mailing Address - Country:US
Mailing Address - Phone:317-535-7141
Mailing Address - Fax:
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:46143-6484
Practice Address - Country:US
Practice Address - Phone:317-535-7141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STACY D JOHNSON DDS PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental