Provider Demographics
NPI:1205295680
Name:JOHNSON, KIA SHERETTE MARLEY (DMD)
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:SHERETTE MARLEY
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 1:2101 PETERS CREEK PKWY STE 16-19
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-3726
Mailing Address - Country:US
Mailing Address - Phone:336-293-8728
Mailing Address - Fax:
Practice Address - Street 1:1901 WESTRIDGE RD STE 102
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-2425
Practice Address - Country:US
Practice Address - Phone:336-517-1132
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10350122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist