Basic Information
| Provider Information | |||||||||
| NPI: | 1891706529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1811 ARMY BLVD BLDG 2018 | ||||||||
| Address2: | |||||||||
| City: | JBSA FT SAM HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782342686 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102210835 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2133 PEPPERRELL ST | ||||||||
| Address2: | |||||||||
| City: | LACKLAND AFB | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782365313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102928628 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 5336421-9922 | UT | N | Dental Providers | Dentist | General Practice | 1223X0400X | 5336421-9922 | UT | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.