Provider Demographics
NPI:1760943542
Name:JOHNSON, TALIA MARIE
Entity Type:Individual
Prefix:
First Name:TALIA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5040 SNAPFINGER WOODS DR STE 203
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-4020
Mailing Address - Country:US
Mailing Address - Phone:269-352-3087
Mailing Address - Fax:
Practice Address - Street 1:5040 SNAPFINGER WOODS DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30035-4020
Practice Address - Country:US
Practice Address - Phone:269-352-3087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-26
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN122957122300000X
NC114331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist