Provider Demographics
NPI:1396346052
Name:JOHNSON, AMY (RDH)
Entity type:Individual
Prefix:
First Name:AMY
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 1:745 BLUE HERON PT
Mailing Address - Street 2:
Mailing Address - City:COUNCE
Mailing Address - State:TN
Mailing Address - Zip Code:38326-4320
Mailing Address - Country:US
Mailing Address - Phone:731-607-4140
Mailing Address - Fax:
Practice Address - Street 1:1480 FLORENCE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-5205
Practice Address - Country:US
Practice Address - Phone:731-925-5346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-07
Last Update Date:2020-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3693124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist