MEDICARE: JOHNSON FAMILY DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist

General Provider Information

NPI Number	:	1255752614
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHNSON FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	722 HARVARD DR
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42301-6152
Country	:	US
Telephone Number	:	270-685-5242
Fax Number	:	270-685-5247

Provider Business Practice Location Address
First Line	:	722 HARVARD DR
Second Line	:
City	:	OWENSBORO
State	:	KY
Zip	:	42301-6152
Country	:	US
Telephone Number	:	270-685-5242
Fax Number	:	270-685-5247

Authorized Official
Title or Position	:	PARTNER
Name	:	DR. MATTHEW JOHNSON
Credential	:	DMD
Telephone Number	:	270-685-5242

Provider Enumeration Date	:	01/02/2014
Last Update Date	:	01/02/2014

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