=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366888174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JORDAN LLOYD JOHNSON D.M.D
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2013
-----------------------------------------------------
Last Update Date | 09/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2232 BARDSTOWN RD STE A
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40205-1986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-438-3060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 199 W MAIN ST
-----------------------------------------------------
City | SCOTTSVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42164-1120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-339-0067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9302
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------