Healthcare Provider Details

I. General information

NPI: 1821666595
Provider Name (Legal Business Name): HALEY JUNE JOHNSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/17/2021
Certification Date: 06/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 LAUREL ST
COLUMBIA SC
29204-1019
US

IV. Provider business mailing address

4681 DOVE PT
YORK SC
29745-9602
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-4543
  • Fax:
Mailing address:
  • Phone: 803-235-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDGD.9910GD
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: