MEDICARE: BEVERLY A JOHNSON DDS MPH INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	28126	CA

General Provider Information

NPI Number	:	1962605915
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEVERLY A JOHNSON DDS MPH INC

Provider Business Mailing Address
First Line	:	4151 DON LUIS DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4214
Country	:	US
Telephone Number	:	310-702-5475
Fax Number	:

Provider Business Practice Location Address
First Line	:	4151 DON LUIS DR
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90008-4214
Country	:	US
Telephone Number	:	310-702-5475
Fax Number	:	310-702-5475

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BEVERLY JOHNSON
Credential	:	DDS
Telephone Number	:	310-702-5475

Provider Enumeration Date	:	06/07/2007
Last Update Date	:	06/03/2011

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