Healthcare Provider Details

I. General information

NPI: 1609885524
Provider Name (Legal Business Name): NEALE WAYNE JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W. SMITH DR.
STOCKTON MO
65785-0609
US

IV. Provider business mailing address

PO BOX 609
STOCKTON MO
65785-0609
US

V. Phone/Fax

Practice location:
  • Phone: 417-276-4417
  • Fax: 417-276-6279
Mailing address:
  • Phone: 417-276-4417
  • Fax: 417-276-6279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11955
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: