Provider Demographics
NPI:1487748471
Name:JOHNSON, TRACEY PERRY (RDH)
Entity type:Individual
Prefix:MRS
First Name:TRACEY
Middle Name:PERRY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:MS
Other - First Name:TRACEY
Other - Middle Name:
Other - Last Name:PERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 TRAM RD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NC
Mailing Address - Zip Code:28390
Mailing Address - Country:US
Mailing Address - Phone:910-960-6266
Mailing Address - Fax:
Practice Address - Street 1:103 SUPERIOR DRIVE
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390
Practice Address - Country:US
Practice Address - Phone:910-497-3200
Practice Address - Fax:910-497-2209
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4623124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist