Provider Demographics
NPI:1972742302
Name:SOUTH PLAINS PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:SOUTH PLAINS PEDIATRIC DENTAL GROUP
Other - Org Name:JOHN S JOHNSON, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-687-8080
Mailing Address - Street 1:5102 SALEM AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-4036
Mailing Address - Country:US
Mailing Address - Phone:806-687-8080
Mailing Address - Fax:806-771-6862
Practice Address - Street 1:5102 SALEM AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-4036
Practice Address - Country:US
Practice Address - Phone:806-687-8080
Practice Address - Fax:806-771-6862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX170871223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX079145101OtherCSHCN (PROGRAM IN TEXAS FOR DISABLED CHILDREN)