Provider Demographics
NPI:1487613816
Name:JOHNSON, TESSA JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:TESSA
Middle Name:JEAN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 VERMONT ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-3119
Mailing Address - Country:US
Mailing Address - Phone:217-223-5611
Mailing Address - Fax:217-223-5650
Practice Address - Street 1:1415 VERMONT ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3119
Practice Address - Country:US
Practice Address - Phone:217-223-5611
Practice Address - Fax:217-223-5650
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9177134Medicaid