Healthcare Provider Details

I. General information

NPI: 1629812029
Provider Name (Legal Business Name): JOHAN THOMAS MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2024
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KNEELAND ST
BOSTON MA
02111-1527
US

IV. Provider business mailing address

6550 HAMPTON ROADS PKWY STE 105
SUFFOLK VA
23435-2754
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-6828
  • Fax:
Mailing address:
  • Phone: 757-484-4205
  • Fax: 757-484-4204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number0401420221
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: