Healthcare Provider Details

I. General information

NPI: 1962659631
Provider Name (Legal Business Name): MATTHEW W JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 HALCYON SUMMIT DRIVE
MONTGOMERY AL
36117-7047
US

IV. Provider business mailing address

7200 HALCYON SUMMIT DRIVE
MONTGOMERY AL
36117-7047
US

V. Phone/Fax

Practice location:
  • Phone: 334-277-3492
  • Fax: 334-277-9432
Mailing address:
  • Phone: 334-277-3492
  • Fax: 334-277-9432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5406
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: