Provider Demographics
NPI:1639174162
Name:JOHNSON, JOHN ANTHONY (DMD, MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ANTHONY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:858 BRAWLEY SCHOOL RD
Mailing Address - Street 2:STE C
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-6852
Mailing Address - Country:US
Mailing Address - Phone:704-799-3555
Mailing Address - Fax:704-799-3095
Practice Address - Street 1:858 BRAWLEY SCHOOL RD
Practice Address - Street 2:STE C
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-6852
Practice Address - Country:US
Practice Address - Phone:704-799-3555
Practice Address - Fax:704-799-3095
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89136CUMedicaid
NCH76694Medicare UPIN
NC2001524AMedicare ID - Type Unspecified