Healthcare Provider Details

I. General information

NPI: 1497334163
Provider Name (Legal Business Name): MALIK LAMAR JOHNSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 WASHINGTON AVE APT 515
NEW ORLEANS LA
70125-1770
US

IV. Provider business mailing address

4650 WASHINGTON AVE APT 515
NEW ORLEANS LA
70125-1770
US

V. Phone/Fax

Practice location:
  • Phone: 704-807-5948
  • Fax:
Mailing address:
  • Phone: 704-807-5948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12645
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: