MEDICARE: CHARLES KEITH JOHNSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5082	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	103763	OTHER	VA	ANTHEM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	805392	OTHER	VA	UNITED CONCORDIA

General Provider Information

NPI Number	:	1013950492
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLES KEITH JOHNSON DDS

Provider Business Mailing Address
First Line	:	1405 WESTOVER HILLS BLVD
Second Line	:	#1
City	:	RICHMOND
State	:	VA
Zip	:	23225
Country	:	US
Telephone Number	:	804-232-1533
Fax Number	:	804-232-1560

Provider Business Practice Location Address
First Line	:	1405 WESTOVER HILLS BLVD
Second Line	:	#1
City	:	RICHMOND
State	:	VA
Zip	:	23225
Country	:	US
Telephone Number	:	804-232-1533
Fax Number	:	804-232-1560

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2006
Last Update Date	:	07/24/2012

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