Healthcare Provider Details

I. General information

NPI: 1912043282
Provider Name (Legal Business Name): WILLIAM R JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4007 VALLEY VIEW DRIVE
LOUISVILLE KY
40216
US

IV. Provider business mailing address

4007 VALLEY VIEW DRIVE
LOUISVILLE KY
40216
US

V. Phone/Fax

Practice location:
  • Phone: 502-448-0678
  • Fax: 502-448-6292
Mailing address:
  • Phone: 502-448-0678
  • Fax: 502-448-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number5700
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: