Provider Demographics
NPI:1861505141
Name:JOHNSON, DURWOOD M JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:DURWOOD
Middle Name:M
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1260 HWY 54 W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214
Mailing Address - Country:US
Mailing Address - Phone:770-461-2101
Mailing Address - Fax:770-460-1292
Practice Address - Street 1:1260 HWY 54 W
Practice Address - Street 2:SUITE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214
Practice Address - Country:US
Practice Address - Phone:770-461-2101
Practice Address - Fax:770-460-1292
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2012-06-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA7973204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000189351BMedicaid
GA000189351BMedicaid
U22627Medicare UPIN