MEDICARE: KELLIE ANITA 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	1223G0001X	General Practice Dentistry	21194	TX

General Provider Information

NPI Number	:	1346337375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE ANITA JOHNSON DDS

Provider Business Mailing Address
First Line	:	6300 WEST LOOP S STE 650
Second Line	:
City	:	BELLAIRE
State	:	TX
Zip	:	77401-2997
Country	:	US
Telephone Number	:	713-663-7960
Fax Number	:

Provider Business Practice Location Address
First Line	:	815 E BERRY ST # B
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76110-4414
Country	:	US
Telephone Number	:	817-920-5919
Fax Number	:

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	07/08/2007

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