Provider Demographics
NPI:1154537165
Name:JOHNSON, FRED THOMAS (DMD)
Entity type:Individual
Prefix:
First Name:FRED
Middle Name:THOMAS
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 1:2020 ROSEDALE RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36605-3167
Mailing Address - Country:US
Mailing Address - Phone:251-476-6966
Mailing Address - Fax:251-476-6967
Practice Address - Street 1:2020 ROSEDALE RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36605-3167
Practice Address - Country:US
Practice Address - Phone:251-476-6966
Practice Address - Fax:251-476-6967
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALLNO42331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice