Provider Demographics
NPI:1639661614
Name:JOHNSON, JASON LEE (DMD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:LEE
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 1:2093 JONESBORO RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-5993
Mailing Address - Country:US
Mailing Address - Phone:770-898-2066
Mailing Address - Fax:
Practice Address - Street 1:2093 JONESBORO RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-5993
Practice Address - Country:US
Practice Address - Phone:770-898-2066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0156401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice