Provider Demographics
NPI:1811147598
Name:JOHNSON, LARRY A (DDS)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
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 1:69 HALL ROAD
Mailing Address - Street 2:
Mailing Address - City:STURBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:07566
Mailing Address - Country:US
Mailing Address - Phone:508-347-2673
Mailing Address - Fax:508-847-5085
Practice Address - Street 1:69 HALL ROAD
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:07566
Practice Address - Country:US
Practice Address - Phone:508-347-2673
Practice Address - Fax:508-847-5085
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA123561223P0300X
CT0061251223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics