Provider Demographics
NPI:1962585497
Name:JOHNSON, JAMIE DEVON (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMIE
Middle Name:DEVON
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 HACKBERRY LN
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-3115
Mailing Address - Country:US
Mailing Address - Phone:205-349-4716
Mailing Address - Fax:205-349-4718
Practice Address - Street 1:1102 HACKBERRY LN
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-3115
Practice Address - Country:US
Practice Address - Phone:205-349-4716
Practice Address - Fax:205-349-4718
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL47101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALU55971Medicare UPIN