Provider Demographics
NPI:1891437695
Name:JOHNSON, DALLAS
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 GARDNER RD
Mailing Address - Street 2:
Mailing Address - City:FOUR OAKS
Mailing Address - State:NC
Mailing Address - Zip Code:27524-8681
Mailing Address - Country:US
Mailing Address - Phone:919-796-2527
Mailing Address - Fax:
Practice Address - Street 1:936 GARDNER RD
Practice Address - Street 2:
Practice Address - City:FOUR OAKS
Practice Address - State:NC
Practice Address - Zip Code:27524-8681
Practice Address - Country:US
Practice Address - Phone:919-796-2527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider