Provider Demographics
NPI:1851516975
Name:JOHNSON, NICHOLAS D (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 BEACON CV
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-5892
Mailing Address - Country:US
Mailing Address - Phone:404-432-5059
Mailing Address - Fax:
Practice Address - Street 1:644 CHEROKEE ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-8910
Practice Address - Country:US
Practice Address - Phone:770-424-6569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0133661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice