Provider Demographics
NPI:1427324243
Name:JOHNSON, MICHAEL ALLAN (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ALLAN
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 1:133 TOWNE CENTRE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3493
Mailing Address - Country:US
Mailing Address - Phone:843-449-1621
Mailing Address - Fax:843-903-3840
Practice Address - Street 1:133 TOWNE CENTRE PARKWAY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3493
Practice Address - Country:US
Practice Address - Phone:843-449-1621
Practice Address - Fax:843-903-3840
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9581223S0112X
SC8911122300000X
MSPRV-FP-105-171223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC958OtherORAL & MAXILLOFACIAL SURGERY LICENSE
SC8811OtherDENTAL LICENSE