Provider Demographics
NPI:1629216726
Name:JOHNSON, MICHAEL LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 CASSIDY RD
Mailing Address - Street 2:
Mailing Address - City:FORT BLISS
Mailing Address - State:TX
Mailing Address - Zip Code:79916-3502
Mailing Address - Country:US
Mailing Address - Phone:915-742-0086
Mailing Address - Fax:
Practice Address - Street 1:BLDG 171, 4TH & INNERLOOP
Practice Address - Street 2:USA DENTAC
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-5076
Practice Address - Country:US
Practice Address - Phone:719-526-5537
Practice Address - Fax:719-524-2843
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57817122300000X, 1223G0001X
CADDS578171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist