MEDICARE: DR. LAURIS WALLACE JOHNSON DMD

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN16876	FL

General Provider Information

NPI Number	:	1558543066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURIS WALLACE JOHNSON DMD

Provider Business Mailing Address
First Line	:	3621 VININGS SLOPE SE
Second Line	:	3309
City	:	ATLANTA
State	:	GA
Zip	:	30339-4107
Country	:	US
Telephone Number	:	770-235-7618
Fax Number	:

Provider Business Practice Location Address
First Line	:	3621 VININGS SLOPE SE
Second Line	:	3309
City	:	ATLANTA
State	:	GA
Zip	:	30339-4107
Country	:	US
Telephone Number	:	770-235-7618
Fax Number	:

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

Provider Enumeration Date	:	11/27/2007
Last Update Date	:	04/03/2012

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