Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 15550 | MD |
NPI | 1023451325 |
---|---|
Provider Name | Michia Johnson |
First Address | Waldorf, MD 20602-3248 |
Second Address | Waldorf, MD 20602-3248 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/04/2013 |
Last Update Date | 29/07/2014 |