Provider Demographics
NPI:1851702872
Name:FUSION DENTAL AT CLEAR CREEK PLLC
Entity Type:Organization
Organization Name:FUSION DENTAL AT CLEAR CREEK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-213-5773
Mailing Address - Street 1:4102 S CLEAR CREEK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-5954
Mailing Address - Country:US
Mailing Address - Phone:254-213-5773
Mailing Address - Fax:
Practice Address - Street 1:4102 S CLEAR CREEK RD STE 102
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-5954
Practice Address - Country:US
Practice Address - Phone:254-213-5773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty