MEDICARE: MR. RANDY 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	1223G0001X	General Practice Dentistry	3056	SC
2	1223G0001X	General Practice Dentistry	8902	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871716225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY JOHNSON DMD

Provider Business Mailing Address
First Line	:	3053 FREEDOM DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-3859
Country	:	US
Telephone Number	:	704-393-3911
Fax Number	:	704-392-1096

Provider Business Practice Location Address
First Line	:	3053 FREEDOM DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-3859
Country	:	US
Telephone Number	:	704-393-3911
Fax Number	:	704-392-1096

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

Provider Enumeration Date	:	04/11/2007
Last Update Date	:	08/06/2012

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