Provider Demographics
NPI:1639597222
Name:DANIEL CRANDALL JOHNSON
Entity Type:Organization
Organization Name:DANIEL CRANDALL JOHNSON
Other - Org Name:AUSTIN CENTRAL PARK PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:CRANDALL
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-330-4624
Mailing Address - Street 1:1005 W 38TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1042
Mailing Address - Country:US
Mailing Address - Phone:512-330-4624
Mailing Address - Fax:
Practice Address - Street 1:1005 W 38TH ST STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1042
Practice Address - Country:US
Practice Address - Phone:512-330-4624
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX287841223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1619250123OtherINDIVIDUAL NPI
TX3194185-03Medicaid