Provider Demographics
NPI:1912317900
Name:JOHNSON, MAXWELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:MAXWELL
Middle Name:
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 1:10195 N ORACLE RD
Mailing Address - Street 2:STE. #111
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-8749
Mailing Address - Country:US
Mailing Address - Phone:520-219-7004
Mailing Address - Fax:520-291-9811
Practice Address - Street 1:10195 N ORACLE RD
Practice Address - Street 2:STE. #111
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-8749
Practice Address - Country:US
Practice Address - Phone:520-219-7004
Practice Address - Fax:520-291-9811
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-30
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist