Healthcare Provider Details

I. General information

NPI: 1851698740
Provider Name (Legal Business Name): RICHARD E JOHNSON DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 02/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5646 N PALM AVE SUITE 101
FRESNO CA
93704-1848
US

IV. Provider business mailing address

2970 E PRYOR DR
FRESNO CA
93720-4498
US

V. Phone/Fax

Practice location:
  • Phone: 559-431-6626
  • Fax: 559-431-6499
Mailing address:
  • Phone: 559-940-0876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22814
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number22814
License Number StateCA

VIII. Authorized Official

Name: DR. RICHARD EVANS JOHNSON
Title or Position: OWNER
Credential: DDS
Phone: 559-431-6626