Provider Demographics
NPI:1770063208
Name:JOHNSON, AUSTIN C (DDS)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:C
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 1:140 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ROBERT
Mailing Address - State:MO
Mailing Address - Zip Code:65584-8614
Mailing Address - Country:US
Mailing Address - Phone:901-643-7576
Mailing Address - Fax:
Practice Address - Street 1:12720 KANSAS AVE
Practice Address - Street 2:BOAK DENTAL CLINIC FORT LEONARD WOOD
Practice Address - City:APO
Practice Address - State:AA
Practice Address - Zip Code:65584
Practice Address - Country:US
Practice Address - Phone:573-596-1470
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-15
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000107691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice