MEDICARE: DR. RAYMOND GORDON JOHNSON JR. 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	7587GEORGIA	GA

General Provider Information

NPI Number	:	1831272376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RAYMOND GORDON JOHNSON JR. DDS

Provider Business Mailing Address
First Line	:	2260 NORTHLAKE PARKWAY
Second Line	:	SUITE 220
City	:	TUCKER
State	:	GA
Zip	:	30084-4006
Country	:	US
Telephone Number	:	770-492-0250
Fax Number	:	770-492-0750

Provider Business Practice Location Address
First Line	:	2260 NORTHLAKE PARKWAY
Second Line	:	SUITE 220
City	:	TUCKER
State	:	GA
Zip	:	30084-4006
Country	:	US
Telephone Number	:	770-492-0250
Fax Number	:	770-492-0750

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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