Provider Demographics
NPI:1962659631
Name:JOHNSON, MATTHEW W (DMD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:W
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 1:7200 HALCYON SUMMIT DRIVE
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-7047
Mailing Address - Country:US
Mailing Address - Phone:334-277-3492
Mailing Address - Fax:334-277-9432
Practice Address - Street 1:7200 HALCYON SUMMIT DRIVE
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-7047
Practice Address - Country:US
Practice Address - Phone:334-277-3492
Practice Address - Fax:334-277-9432
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL54061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL110607Medicaid
AL110619Medicaid
2105769OtherUNITED CONCORDIA
AL510-49384OtherBLUE CROSS AND BLUE SHIELD
AL110617Medicaid
AL102I853223Medicare PIN
2105769OtherUNITED CONCORDIA
AL102I853223Medicare PIN