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General NPI Number Information
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NPI Number | 1912487505
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Entity Type | Individual
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Provider Name | DR. DWIGHT JOHNSON
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Gender | Male
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Dates
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Enumeration Date | 08/14/2018
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Last Update Date | 08/14/2018
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Provider Practice Location Address
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Address Line | 12200 15TH ST STE 106
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City | GRANDVIEW
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State | MO
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Zip | 64030-1772
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Country | US
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Telephone | 816-398-8046
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Fax |
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Provider Business Mailing Address
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Address Line | 701 E ARMOUR BLVD APT 506
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City | KANSAS CITY
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State | MO
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Zip | 64109-2303
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Country | US
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Telephone | 630-767-9740
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2018021651
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License Number State | MO
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