MEDICARE: DR. MATTHEW L JOHNSON DMD

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	8486	KY
2	1223G0001X	General Practice Dentistry	KY8486	KY

General Provider Information

NPI Number	:	1295920411
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MATTHEW L JOHNSON DMD

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/11/2007
Last Update Date	:	11/10/2009

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