Healthcare Provider Details

I. General information

NPI: 1336141068
Provider Name (Legal Business Name): JOHN M JOHNSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 GOLD STAR HWY
GROTON CT
06340-6267
US

IV. Provider business mailing address

643 GOLD STAR HWY
GROTON CT
06340-6267
US

V. Phone/Fax

Practice location:
  • Phone: 860-445-8569
  • Fax: 860-446-1890
Mailing address:
  • Phone: 860-445-8569
  • Fax: 860-446-1890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6800
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: