Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223P0300X | Periodontist | 11759 | MD |
Y | 1223P0300X | Periodontist | 3116/PERIO 470 | SC |
NPI | 1114921491 |
---|---|
Provider Name | Dr. Karen Evangeline Johnson |
First Address | Columbia, SC 29223 |
Second Address | Columbia, SC 29223 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/06/2005 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Z31163 | (05) | SC |