Provider Demographics
NPI:1154965549
Name:JOHNSON, WESLEY JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:JOSEPH
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 1:8950 US HIGHWAY 64 STE 108
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:TN
Mailing Address - Zip Code:38002-4566
Mailing Address - Country:US
Mailing Address - Phone:901-308-5952
Mailing Address - Fax:
Practice Address - Street 1:8950 US HIGHWAY 64 STE 108
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:TN
Practice Address - Zip Code:38002-4566
Practice Address - Country:US
Practice Address - Phone:901-308-5952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-29
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty