Provider Demographics
NPI:1104994052
Name:JOHNSON, HENDERSON ANDREW IV (DDS)
Entity type:Individual
Prefix:DR
First Name:HENDERSON
Middle Name:ANDREW
Last Name:JOHNSON
Suffix:IV
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 1:2475 E 22ND ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44115-3221
Mailing Address - Country:US
Mailing Address - Phone:216-566-7770
Mailing Address - Fax:216-566-7704
Practice Address - Street 1:2475 E 22ND ST
Practice Address - Street 2:SUITE 204
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44115-3221
Practice Address - Country:US
Practice Address - Phone:216-566-7770
Practice Address - Fax:216-566-7704
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH179341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0668406Medicaid