Healthcare Provider Details

I. General information

NPI: 1447964754
Provider Name (Legal Business Name): DR. LAREE JOHNSON PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2023
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 NEW BERN AVE
RALEIGH NC
27610-1821
US

IV. Provider business mailing address

182 INDUSTRIAL RD
GLEN ROCK PA
17327-8626
US

V. Phone/Fax

Practice location:
  • Phone: 919-526-1000
  • Fax: 833-516-9244
Mailing address:
  • Phone: 717-759-4375
  • Fax: 717-759-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: LAREE JOHNSON
Title or Position: OWNER
Credential: DDS
Phone: 919-526-1000