Provider Demographics
NPI:1932266145
Name:JOHNSON, JEFF O (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:O
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 1:16 MILLS AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29605-4065
Mailing Address - Country:US
Mailing Address - Phone:864-271-3463
Mailing Address - Fax:864-271-9514
Practice Address - Street 1:16 MILLS AVE STE 4
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4065
Practice Address - Country:US
Practice Address - Phone:864-271-3463
Practice Address - Fax:864-271-9514
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC33241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZX3324Medicaid