Healthcare Provider Details

I. General information

NPI: 1346698396
Provider Name (Legal Business Name): JEFFERY JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SOUTHTOWNE DR
POTOSI MO
63664-5729
US

IV. Provider business mailing address

5901 COLONY CHURCH RD
FARMINGTON MO
63640-7424
US

V. Phone/Fax

Practice location:
  • Phone: 573-438-8401
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2016017399
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: