Provider Demographics
NPI:1932723715
Name:JOHNSON, JORDAN TYLER (DDS)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:TYLER
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 1:59 HAYWOOD PARK DR
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NC
Mailing Address - Zip Code:28721-4404
Mailing Address - Country:US
Mailing Address - Phone:828-627-1999
Mailing Address - Fax:828-627-1998
Practice Address - Street 1:59 HAYWOOD PARK DR
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NC
Practice Address - Zip Code:28721-4404
Practice Address - Country:US
Practice Address - Phone:828-627-1999
Practice Address - Fax:828-627-1998
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC130391223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics