Provider Demographics
NPI:1184778110
Name:JOHNSON, BAXTER E (DMD)
Entity type:Individual
Prefix:DR
First Name:BAXTER
Middle Name:E
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 1:501 S PRESTON ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40292-0001
Mailing Address - Country:US
Mailing Address - Phone:502-852-5128
Mailing Address - Fax:502-852-7163
Practice Address - Street 1:501 S PRESTON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40292-0001
Practice Address - Country:US
Practice Address - Phone:502-852-5128
Practice Address - Fax:502-852-7163
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6185122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0004490OtherDORAL DENTAL
KY60061850Medicaid