Provider Demographics
NPI:1194873240
Name:JOHNSON, REBECCA (RDH)
Entity type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2906 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-5288
Mailing Address - Country:US
Mailing Address - Phone:812-279-6455
Mailing Address - Fax:812-279-0130
Practice Address - Street 1:2906 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-5288
Practice Address - Country:US
Practice Address - Phone:812-279-6455
Practice Address - Fax:812-279-0130
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN13005334A124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN13005334AOtherREGISTERED DENTAL HYGIENE