MEDICARE: MONIQUE OLIVIA JOHNSON

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	DN015512	GA

General Provider Information

NPI Number	:	1518326727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MONIQUE OLIVIA JOHNSON

Provider Business Mailing Address
First Line	:	1954 LOWN FARM TRAIL
Second Line	:	DEPT OF DENTISTRY-6TH FLOOR
City	:	LITHONIA
State	:	GA
Zip	:	30058-8202
Country	:	US
Telephone Number	:	678-215-3259
Fax Number	:

Provider Business Practice Location Address
First Line	:	3752 CASCADE RD SW STE 190
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30331-2149
Country	:	US
Telephone Number	:	678-836-2118
Fax Number	:

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

Provider Enumeration Date	:	02/16/2016
Last Update Date	:	07/21/2022

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