Healthcare Provider Details

I. General information

NPI: 1780662791
Provider Name (Legal Business Name): THOMAS MICHAEL JOHNSON DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 03/03/2023
Certification Date: 03/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 E HOSPITAL RD
FORT GORDON GA
30905-6011
US

IV. Provider business mailing address

BUILDING 38801, SUITES B & C
FORT GORDON GA
30905-5660
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-6819
  • Fax:
Mailing address:
  • Phone: 706-787-6927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number30-022175
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: