Provider Demographics
NPI:1811266646
Name:EDDIE P JOHNSON III, DMD, PC
Entity type:Organization
Organization Name:EDDIE P JOHNSON III, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-790-9179
Mailing Address - Street 1:2755 BARTON CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-9579
Mailing Address - Country:US
Mailing Address - Phone:706-790-9179
Mailing Address - Fax:706-790-3408
Practice Address - Street 1:2755 BARTON CHAPEL RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906
Practice Address - Country:US
Practice Address - Phone:706-790-9179
Practice Address - Fax:706-790-3408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-23
Last Update Date:2011-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA009685305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00254526CMedicaid