Healthcare Provider Details

I. General information

NPI: 1871584565
Provider Name (Legal Business Name): JERRY ALAN JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 E WASHINGTON BLVD
PASADENA CA
91104-1944
US

IV. Provider business mailing address

2295 E WASHINGTON BLVD
PASADENA CA
91104-1944
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-7896
  • Fax:
Mailing address:
  • Phone: 626-798-7896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: