Healthcare Provider Details

I. General information

NPI: 1215908975
Provider Name (Legal Business Name): GERALD F JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 827 BOX 543
FPO AE
09617
IT

IV. Provider business mailing address

PSC 827 BOX 543
FPO AE
09617
IT

V. Phone/Fax

Practice location:
  • Phone: 81-811-5004
  • Fax:
Mailing address:
  • Phone: 81-811-5004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number60170
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: