Provider Demographics
NPI:1386762987
Name:JOHNSON, EDDIE PRINCE III (DMD)
Entity type:Individual
Prefix:DR
First Name:EDDIE
Middle Name:PRINCE
Last Name:JOHNSON
Suffix:III
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 1:3400 HEATHER DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-2795
Mailing Address - Country:US
Mailing Address - Phone:707-736-5421
Mailing Address - Fax:
Practice Address - Street 1:27 5 5 BARTON CHAPEL ROAD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-9579
Practice Address - Country:US
Practice Address - Phone:706-790-9179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9685122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00254526CMedicaid