Provider Demographics
NPI:1932355229
Name:JOHNSON, WALLACE B (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:B
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:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:MAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14757-0126
Mailing Address - Country:US
Mailing Address - Phone:716-753-7612
Mailing Address - Fax:
Practice Address - Street 1:WEST LAKE ROAD
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:14757-0126
Practice Address - Country:US
Practice Address - Phone:716-753-7612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-18
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161107632122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist