Provider Demographics
NPI:1285781807
Name:JOHNSON, JUDITH ANN (RDH)
Entity type:Individual
Prefix:MRS
First Name:JUDITH
Middle Name:ANN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-4014
Mailing Address - Country:US
Mailing Address - Phone:518-483-9644
Mailing Address - Fax:
Practice Address - Street 1:134 PARK ST
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-1251
Practice Address - Country:US
Practice Address - Phone:518-481-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021000124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist