Provider Demographics
NPI:1831694314
Name:WILLIAM R. JOHNSON, DMD
Entity type:Organization
Organization Name:WILLIAM R. JOHNSON, DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/SPOUSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-448-0678
Mailing Address - Street 1:4007 VALLEY VIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-4221
Mailing Address - Country:US
Mailing Address - Phone:502-448-0678
Mailing Address - Fax:502-448-6292
Practice Address - Street 1:4007 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4221
Practice Address - Country:US
Practice Address - Phone:502-448-0678
Practice Address - Fax:502-448-6292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY98051223G0001X
KY57001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100484350Medicaid
KY60057007Medicaid