Provider Demographics
NPI:1316579279
Name:SHANNON P JOHNSON DMD PLLC
Entity type:Organization
Organization Name:SHANNON P JOHNSON DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:POLLY
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-957-9390
Mailing Address - Street 1:2913 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2106
Mailing Address - Country:US
Mailing Address - Phone:502-957-9390
Mailing Address - Fax:
Practice Address - Street 1:9510 ORMSBY STATION RD STE 203
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-4083
Practice Address - Country:US
Practice Address - Phone:502-805-0500
Practice Address - Fax:502-771-6041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-09
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental