Provider Demographics
NPI:1255710810
Name:JOHNSON, MATTHEW JEFFREY JR (MD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JEFFREY
Last Name:JOHNSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:125 TRADE CT # 26
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-5545
Mailing Address - Country:US
Mailing Address - Phone:704-360-9995
Mailing Address - Fax:704-360-2221
Practice Address - Street 1:229 MEDICAL PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8544
Practice Address - Country:US
Practice Address - Phone:704-360-9995
Practice Address - Fax:704-360-2221
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2019-02699208600000X, 1223S0112X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program