Provider Demographics
NPI:1992853337
Name:DR. SAMUEL L. JOHNSON, DDS, P.C.
Entity Type:Organization
Organization Name:DR. SAMUEL L. JOHNSON, DDS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:251-639-0911
Mailing Address - Street 1:740 HILLCREST RD STE 2B
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695-4021
Mailing Address - Country:US
Mailing Address - Phone:251-639-0911
Mailing Address - Fax:251-633-7889
Practice Address - Street 1:740 HILLCREST RD STE 2B
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695-4021
Practice Address - Country:US
Practice Address - Phone:251-639-0911
Practice Address - Fax:251-633-7889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL40491223G0001X
AL5453C1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL81233Medicare UPIN
AL05645Medicare UPIN