Provider Demographics
NPI:1659579647
Name:JOHNSON, KEENON (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:KEENON
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10208 CERNY ST
Mailing Address - Street 2:SUITE 304
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-7884
Mailing Address - Country:US
Mailing Address - Phone:919-706-0617
Mailing Address - Fax:919-825-3361
Practice Address - Street 1:10208 CERNY ST
Practice Address - Street 2:SUITE 304
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7884
Practice Address - Country:US
Practice Address - Phone:919-706-0617
Practice Address - Fax:919-825-3361
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC86691223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics