Healthcare Provider Details

I. General information

NPI: 1821130253
Provider Name (Legal Business Name): JEFFREY W JOHNSON DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 S WOODRUFF AVE
IDAHO FALLS ID
83401-4322
US

IV. Provider business mailing address

333 S WOODRUFF AVE
IDAHO FALLS ID
83401-4322
US

V. Phone/Fax

Practice location:
  • Phone: 208-529-3500
  • Fax: 208-523-9004
Mailing address:
  • Phone: 208-529-3500
  • Fax: 208-523-9004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3190OR
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8041458
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: