Provider Demographics
NPI:1386323343
Name:JOHNSON, MILES TYLER (DDS)
Entity type:Individual
Prefix:
First Name:MILES
Middle Name:TYLER
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 1:703 CONTINENTAL DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-4803
Mailing Address - Country:US
Mailing Address - Phone:404-641-1218
Mailing Address - Fax:
Practice Address - Street 1:7278 HIGHWAY 72 W
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9551
Practice Address - Country:US
Practice Address - Phone:256-217-7815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD.007232-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice