Provider Demographics
NPI:1932185790
Name:JOHNSON, RACQUEL (DMD)
Entity type:Individual
Prefix:DR
First Name:RACQUEL
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 BENTONS LODGE RD STE A
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-6336
Mailing Address - Country:US
Mailing Address - Phone:843-892-1098
Mailing Address - Fax:843-725-1594
Practice Address - Street 1:108 BENTONS LODGE RD STE A
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-6336
Practice Address - Country:US
Practice Address - Phone:843-892-1098
Practice Address - Fax:843-725-1594
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-22
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29016024911223P0221X
NJDI0220191223P0221X
DEG3-00004971223P0221X
TN108891223P0221X
SC112731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223674675OtherTAX ID NUMBER