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General NPI Number Information
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NPI Number | 1851702872
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Entity Type | Organization
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Legal Business Name | FUSION DENTAL AT CLEAR CREEK PLLC
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Dates
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Enumeration Date | 05/13/2014
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | 4102 S CLEAR CREEK RD STE 102
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City | KILLEEN
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State | TX
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Zip | 76549-5954
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Country | US
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Telephone | 254-213-5773
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Fax |
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Provider Business Mailing Address
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Address Line | 4102 S CLEAR CREEK RD STE 102
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City | KILLEEN
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State | TX
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Zip | 76549-5954
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Country | US
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Telephone | 254-213-5773
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | JOHNNY W JOHNSON
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Credential |
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Telephone | 254-213-5773
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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 | 25786
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License Number State | TX
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