Provider Demographics
NPI:1902909021
Name:JOHNSON, JEFFREY O (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:O
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:J
Other - Middle Name:ODELL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DD
Mailing Address - Street 1:PO BOX 27
Mailing Address - Street 2:611 S 13 HWY
Mailing Address - City:LEXINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:64067
Mailing Address - Country:US
Mailing Address - Phone:660-259-2321
Mailing Address - Fax:660-259-2321
Practice Address - Street 1:611 S 13 HWY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067
Practice Address - Country:US
Practice Address - Phone:660-259-2321
Practice Address - Fax:660-259-2321
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist