Provider Demographics
NPI:1861841470
Name:JOHNSON, LEAH MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:LEAH
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LEAH
Other - Middle Name:MARIE
Other - Last Name:GHARRITY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1101 SOUTH AIRLINE ROAD
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406
Mailing Address - Country:US
Mailing Address - Phone:262-637-9243
Mailing Address - Fax:
Practice Address - Street 1:1101 SOUTH AIRLINE ROAD
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53406
Practice Address - Country:US
Practice Address - Phone:262-637-9243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-06
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1001341-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program