Provider Demographics
NPI:1912128398
Name:JOHNSON, JUDY (DDS)
Entity type:Individual
Prefix:DR
First Name:JUDY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10604-2146
Mailing Address - Country:US
Mailing Address - Phone:914-686-2225
Mailing Address - Fax:
Practice Address - Street 1:192 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEST HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10604-2146
Practice Address - Country:US
Practice Address - Phone:914-686-2225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0363161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00715059Medicaid