Provider Demographics
NPI:1669624003
Name:RODEN-JOHNSON, DUSTIN DANIEL (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:DUSTIN
Middle Name:DANIEL
Last Name:RODEN-JOHNSON
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HWY 71 WEST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-4111
Mailing Address - Country:US
Mailing Address - Phone:512-321-1000
Mailing Address - Fax:
Practice Address - Street 1:301 HIGHWAY 71 W
Practice Address - Street 2:SUITE 201
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4105
Practice Address - Country:US
Practice Address - Phone:512-321-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX221091223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics