Provider Demographics
NPI:1134509672
Name:JOHNSON, LAURA TERESA (DMD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:TERESA
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 1:4218 WALNUT ST APT 3F
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5255
Mailing Address - Country:US
Mailing Address - Phone:863-670-8674
Mailing Address - Fax:
Practice Address - Street 1:4218 WALNUT ST APT 3F
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5255
Practice Address - Country:US
Practice Address - Phone:863-670-8674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-30
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program