Healthcare Provider Details

I. General information

NPI: 1699945311
Provider Name (Legal Business Name): THOMAS A. JOHNSON, DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 UPPER HEMBREE RD SUITE 201
ROSWELL GA
30076-1146
US

IV. Provider business mailing address

1360 UPPER HEMBREE RD SUITE 201
ROSWELL GA
30076-1146
US

V. Phone/Fax

Practice location:
  • Phone: 770-475-3361
  • Fax: 770-664-4431
Mailing address:
  • Phone: 770-475-3361
  • Fax: 770-664-4431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License NumberDN007750
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License NumberDN0007750
License Number StateGA

VIII. Authorized Official

Name: THOMAS ANTHONY JOHNSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 770-475-3361