Provider Demographics
NPI:1619985272
Name:JOHNSON, DARYL LANCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:LANCE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1313 W HIGHWAY 8
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2240
Mailing Address - Country:US
Mailing Address - Phone:662-843-8353
Mailing Address - Fax:662-843-8303
Practice Address - Street 1:1313 W HIGHWAY 8
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2240
Practice Address - Country:US
Practice Address - Phone:662-843-8353
Practice Address - Fax:662-843-8303
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2826-941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660091Medicaid