Healthcare Provider Details

I. General information

NPI: 1649459926
Provider Name (Legal Business Name): JOSEPH G JOHANSEN DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2007
Last Update Date: 11/02/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3048 E BASELINE RD SUITE #105
MESA AZ
85204-7286
US

IV. Provider business mailing address

3048 E BASELINE RD SUITE #105
MESA AZ
85204-7286
US

V. Phone/Fax

Practice location:
  • Phone: 480-632-8848
  • Fax:
Mailing address:
  • Phone: 480-632-8848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberAZ3185
License Number StateAZ

VIII. Authorized Official

Name: JOSEPH GRANT JOHANSEN
Title or Position: ORAL MAXILLOFACIAL SURGEON
Credential: DDS
Phone: 480-632-1508