Provider Demographics
NPI:1992110894
Name:JOHNSON, JEFFREY (DDS)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
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 1:2120 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4646
Mailing Address - Country:US
Mailing Address - Phone:940-761-5979
Mailing Address - Fax:
Practice Address - Street 1:2120 VIRGINIA DR
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4646
Practice Address - Country:US
Practice Address - Phone:940-761-5979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30183122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist