Provider Demographics
NPI:1538241427
Name:JOHNSON, DONALD RICHARD JR (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:RICHARD
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 HARRIS AVE
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-3113
Mailing Address - Country:US
Mailing Address - Phone:910-875-8181
Mailing Address - Fax:910-875-6361
Practice Address - Street 1:718 HARRIS AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3113
Practice Address - Country:US
Practice Address - Phone:910-875-8181
Practice Address - Fax:910-875-6361
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8994606Medicaid
NC8994606Medicaid