=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801215827
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHAD E JOHNSON DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2014
-----------------------------------------------------
Last Update Date | 04/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2335 KNOB CREEK RD SUITE 107
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-282-1030
-----------------------------------------------------
Fax | 423-282-4714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2335 KNOB CREEK RD SUITE 107
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37604-2002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-282-1030
-----------------------------------------------------
Fax | 423-282-4714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | VALERIE S CALLAHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-282-1030
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 9466
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 8138
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------