Provider Demographics
NPI:1629299847
Name:CHARLES D. JOHNSON, DDS
Entity Type:Organization
Organization Name:CHARLES D. JOHNSON, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RORIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:662-728-8133
Mailing Address - Street 1:607 W CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-2647
Mailing Address - Country:US
Mailing Address - Phone:662-728-8133
Mailing Address - Fax:662-728-6903
Practice Address - Street 1:607 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:MS
Practice Address - Zip Code:38829-2647
Practice Address - Country:US
Practice Address - Phone:662-728-8133
Practice Address - Fax:662-728-6903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00004329Medicaid