Healthcare Provider Details

I. General information

NPI: 1831606094
Provider Name (Legal Business Name): DJR2 PROFESSIONAL LIMITED LIABILITY COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2018
Last Update Date: 01/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S 4TH ST STE 201
DANVILLE KY
40422-2091
US

IV. Provider business mailing address

2505 LARKIN RD STE 201
LEXINGTON KY
40503-3256
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-8448
  • Fax:
Mailing address:
  • Phone: 859-396-3347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY TODD JOHNSON
Title or Position: MANAGER
Credential: DMD, MPH
Phone: 859-327-4711