Healthcare Provider Details

I. General information

NPI: 1093909558
Provider Name (Legal Business Name): THE DENTISTS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 08/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

761 S MARINE CORPS DRIVE SUITE A-2 CENTAM BUILDING
TAMUNING GU
96913
US

IV. Provider business mailing address

PO BOX W
HAGATNA GU
96932
US

V. Phone/Fax

Practice location:
  • Phone: 671-646-7982
  • Fax: 671-646-7989
Mailing address:
  • Phone: 671-646-7982
  • Fax: 671-646-7989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD 829
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD 901
License Number StateGU

VIII. Authorized Official

Name: DR. JEFFREY CHARLES JOHNSON
Title or Position: GENERAL PARTNER
Credential: DDS
Phone: 671-646-7982