Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 12008858 | IN |
NPI | 1053397315 |
---|---|
Provider Name | Dr. Diane Johnson |
First Address | Mooresville, IN 46158-1508 |
Second Address | Mooresville, IN 46158-1508 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/12/2005 |
Last Update Date | 08/07/2007 |