Healthcare Provider Details

I. General information

NPI: 1013950492
Provider Name (Legal Business Name): CHARLES KEITH JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 WESTOVER HILLS BLVD #1
RICHMOND VA
23225
US

IV. Provider business mailing address

1405 WESTOVER HILLS BLVD #1
RICHMOND VA
23225
US

V. Phone/Fax

Practice location:
  • Phone: 804-232-1533
  • Fax: 804-232-1560
Mailing address:
  • Phone: 804-232-1533
  • Fax: 804-232-1560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5082
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: