Provider Demographics
NPI:1679654586
Name:JOHNSON, KENNETH DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:DALE
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3102 GARRETT DR
Mailing Address - Street 2:
Mailing Address - City:PERRYTON
Mailing Address - State:TX
Mailing Address - Zip Code:79070-5324
Mailing Address - Country:US
Mailing Address - Phone:806-435-6564
Mailing Address - Fax:806-435-6565
Practice Address - Street 1:3102 GARRETT DR
Practice Address - Street 2:
Practice Address - City:PERRYTON
Practice Address - State:TX
Practice Address - Zip Code:79070-5324
Practice Address - Country:US
Practice Address - Phone:806-435-6564
Practice Address - Fax:806-435-6565
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice