Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 12345191-9922 | UT |
NPI | 1003584996 |
---|---|
Provider Name | Dr. Riley D Johnson |
First Address | Horizon City, TX 79928-7311 |
Second Address | Fort Bliss, TX 79916 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/09/2021 |
Last Update Date | 03/09/2021 |