Healthcare Provider Details

I. General information

NPI: 1982205415
Provider Name (Legal Business Name): STACY D JOHNSON, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3056 W STONES CROSSING RD
GREENWOOD IN
46143-6484
US

IV. Provider business mailing address

3056 W STONES CROSSING RD
GREENWOOD IN
46143-6484
US

V. Phone/Fax

Practice location:
  • Phone: 317-535-7141
  • Fax:
Mailing address:
  • Phone: 317-535-7141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STACY DUANE JOHNSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 317-535-7141