Healthcare Provider Details

I. General information

NPI: 1285426619
Provider Name (Legal Business Name): MARIAH SHIRLANNE CLEARY JOHNSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

449 CAPP HARLAN RD
TOMPKINSVILLE KY
42167-1808
US

IV. Provider business mailing address

449 CAPP HARLAN RD
TOMPKINSVILLE KY
42167-1808
US

V. Phone/Fax

Practice location:
  • Phone: 270-487-0017
  • Fax:
Mailing address:
  • Phone: 270-487-0017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11345
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: