Provider Demographics
NPI:1255645297
Name:JOHNSON, EMILY AHLUM (DMD)
Entity type:Individual
Prefix:DR
First Name:EMILY
Middle Name:AHLUM
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 1:1055 MADISON MARKETPLACE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NY
Mailing Address - Zip Code:13346-2343
Mailing Address - Country:US
Mailing Address - Phone:315-825-3100
Mailing Address - Fax:315-825-3017
Practice Address - Street 1:1055 MADISON MARKETPLACE
Practice Address - Street 2:BASSETT HEALTHCARE HAMILTON-MADISON HEALTH CENTER
Practice Address - City:HAMILTON
Practice Address - State:NY
Practice Address - Zip Code:13346-2343
Practice Address - Country:US
Practice Address - Phone:315-825-3100
Practice Address - Fax:315-825-3017
Is Sole Proprietor?:No
Enumeration Date:2010-08-02
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0549851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03362489Medicaid