Provider Demographics
NPI:1912275439
Name:JOHNSON, JIMMIE LEE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JIMMIE
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:PO BOX 175
Mailing Address - Street 2:87 WILDWOOD PLACE
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-0175
Mailing Address - Country:US
Mailing Address - Phone:606-723-3213
Mailing Address - Fax:606-723-3213
Practice Address - Street 1:87 WILDWOOD PLACE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-1312
Practice Address - Country:US
Practice Address - Phone:606-723-3213
Practice Address - Fax:606-723-3213
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60061637Medicaid