Provider Demographics
NPI:1437240728
Name:JOHNSON, MATTHEW JEFFREY (MD, DMD)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JEFFREY
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 MEDICAL PARK RD STE 310
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8544
Mailing Address - Country:US
Mailing Address - Phone:704-799-0771
Mailing Address - Fax:704-799-2941
Practice Address - Street 1:229 MEDICAL PARK RD SUITE 310
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-8522
Practice Address - Country:US
Practice Address - Phone:704-799-0771
Practice Address - Fax:704-799-2941
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99005561223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8742082OtherUNITED HEALTHCARE
NC891218UMedicaid
NC1218UOtherBCBS
NC5738691002OtherCIGNA
NC536660OtherUNITED CONCORDIA DENTAL
NC7082247OtherAETNA
NC89902HVOtherMEDICAID DENTAL
NC891218UMedicaid
NC8742082OtherUNITED HEALTHCARE