Healthcare Provider Details

I. General information

NPI: 1467448092
Provider Name (Legal Business Name): ROBERT KIRK JOHNSON DSS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 12/14/2023
Certification Date: 12/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 AVIEMORE DR
PINEHURST NC
28374-9797
US

IV. Provider business mailing address

93 AVIEMORE DR
PINEHURST NC
28374-9797
US

V. Phone/Fax

Practice location:
  • Phone: 910-295-8088
  • Fax: 910-295-8855
Mailing address:
  • Phone: 910-295-8088
  • Fax: 910-295-8855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number9044
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: