1316051600 NPI number — BROWNSBURG DENTAL GROUP PC

Table of content: DOMINIQUE LATRICE JOHNSON DO (NPI 1386218147)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316051600 NPI number — BROWNSBURG DENTAL GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROWNSBURG DENTAL GROUP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316051600
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 E AIRPORT RD
Provider Second Line Business Mailing Address:
SUITE 1100
Provider Business Mailing Address City Name:
BROWNSBURG
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46112-2046
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-852-1446
Provider Business Mailing Address Fax Number:
317-852-1449

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
20 E AIRPORT RD
Provider Second Line Business Practice Location Address:
SUITE 1100
Provider Business Practice Location Address City Name:
BROWNSBURG
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46112-2046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-852-1446
Provider Business Practice Location Address Fax Number:
317-852-1449
Provider Enumeration Date:
08/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FRIEDMAN
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER PRESIDENT
Authorized Official Telephone Number:
317-852-1446

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  12009280 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: 12010164A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)