Provider Demographics
NPI:1295920411
Name:JOHNSON, MATTHEW L (DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
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 1:722 HARVARD DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-6152
Mailing Address - Country:US
Mailing Address - Phone:270-685-5242
Mailing Address - Fax:270-685-5247
Practice Address - Street 1:722 HARVARD DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-6152
Practice Address - Country:US
Practice Address - Phone:270-685-5242
Practice Address - Fax:270-685-5247
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8486122300000X
KYKY84861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice