MEDICARE: THERESA MARIE JOHNSON RDH

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	124Q00000X	Dental Hygienist	009098	OH
2	124Q00000X	Dental Hygienist	13945	TX
3	124Q00000X	Dental Hygienist	8336	NC

General Provider Information

NPI Number	:	1619299245
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MARIE JOHNSON RDH

Provider Business Mailing Address
First Line	:	5900 LONG CT
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730-4919
Country	:	US
Telephone Number	:	512-653-6931
Fax Number	:

Provider Business Practice Location Address
First Line	:	5900 LONG CT
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78730-4919
Country	:	US
Telephone Number	:	512-653-6931
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2010
Last Update Date	:	02/23/2010

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