Provider Demographics
NPI:1962816462
Name:JOHNSON, RAYMOND JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:JAMES
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 1:15 SHADY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:PA
Mailing Address - Zip Code:16345-1135
Mailing Address - Country:US
Mailing Address - Phone:814-688-9214
Mailing Address - Fax:
Practice Address - Street 1:15 SHADY RIDGE RD
Practice Address - Street 2:
Practice Address - City:RUSSELL
Practice Address - State:PA
Practice Address - Zip Code:16345-1135
Practice Address - Country:US
Practice Address - Phone:814-688-9214
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0400041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice