Provider Demographics
NPI:1265274096
Name:JOHNSON, THOMAS (DDS)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:759 PLANTATION LN
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45419-1117
Mailing Address - Country:US
Mailing Address - Phone:937-684-0890
Mailing Address - Fax:
Practice Address - Street 1:4100 W 3RD ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45428-9000
Practice Address - Country:US
Practice Address - Phone:937-684-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.027584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist