Organization
LIFETIME DENTAL LLC
Active
Parent organization
JOHNSON DENTAL CLINIC INC
Organization subpart
Yes
Provider details
NPI number
Legal business name
JOHNSON DENTAL CLINIC INC
Authorized official
DARYL LANCE JOHNSON DMD (SOLE PROPRIETOR)
(662) 843-8353
Entity
Organization
Contact information
Practice address
910 MEDALLION DR, GREENWOOD, MS 38930-2118
(662) 843-8353
(662) 843-8363
Mailing address
1313 W HIGHWAY 8, CLEVELAND, MS 38732-2240
(662) 843-8353
(662) 843-8363
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
2826-94
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09015931
—
MS
Enumeration date
10/17/2016
Last updated
10/17/2016
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