Provider Demographics
NPI:1790980167
Name:JOHNSON, HAROLD CORTEZ (DDS)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:CORTEZ
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 759
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-0759
Mailing Address - Country:US
Mailing Address - Phone:586-758-3620
Mailing Address - Fax:586-758-8279
Practice Address - Street 1:21761 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091
Practice Address - Country:US
Practice Address - Phone:586-758-3620
Practice Address - Fax:586-758-8279
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI013040122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist