Provider Demographics
NPI:1366583387
Name:JOHNSON, JOHN BERNARD III (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BERNARD
Last Name:JOHNSON
Suffix:III
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 1:6215 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3725
Mailing Address - Country:US
Mailing Address - Phone:219-763-1502
Mailing Address - Fax:219-762-3100
Practice Address - Street 1:6215 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3725
Practice Address - Country:US
Practice Address - Phone:219-763-1502
Practice Address - Fax:219-762-3100
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007783A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12007783AOtherSTATE LICENCE