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General NPI Number Information
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NPI Number | 1164599452
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Entity Type | Organization
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Legal Business Name | KEITH D JOHNSON DDS PC
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Dates
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Enumeration Date | 11/29/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 26 S VILLAGE DRIVE
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City | LIBERTY
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State | MO
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Zip | 64068
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Country | US
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Telephone | 816-781-7571
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Fax | 816-781-7933
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Provider Business Mailing Address
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Address Line | 26 S VILLAGE DRIVE
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City | LIBERTY
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State | MO
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Zip | 64068
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Country | US
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Telephone | 816-781-7571
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Fax | 816-781-7933
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Authorized Official
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Title or Position | GENERAL DENTIST OWNER
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Name | DR. KEITH DAVID JOHNSON
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Credential | DDS
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Telephone | 816-781-7571
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 14182
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License Number State | MO
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