Healthcare Provider Details

I. General information

NPI: 1023334711
Provider Name (Legal Business Name): PETER F JOHNSON DMD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 06/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR SUITE 110-1
LA MESA CA
91942-3020
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR SUITE 110-1
LA MESA CA
91942-3020
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-3737
  • Fax: 619-463-3730
Mailing address:
  • Phone: 619-463-3737
  • Fax: 619-463-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD25550
License Number StateCA

VIII. Authorized Official

Name: DR. PETER FINK JOHNSON
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 619-463-3737