Provider Demographics
NPI:1194987602
Name:JOHNSON, ANDREW T (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:T
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 1:1106 ANTHONY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-1730
Mailing Address - Country:US
Mailing Address - Phone:803-252-4500
Mailing Address - Fax:803-252-0334
Practice Address - Street 1:1106 ANTHONY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-1730
Practice Address - Country:US
Practice Address - Phone:803-252-4500
Practice Address - Fax:803-252-0334
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist