Healthcare Provider Details

I. General information

NPI: 1417709239
Provider Name (Legal Business Name): KEANDRA STEWART-JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2024
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E WEST HWY STE G
SILVER SPRING MD
20910-3230
US

IV. Provider business mailing address

1400 E WEST HWY STE G
SILVER SPRING MD
20910-3230
US

V. Phone/Fax

Practice location:
  • Phone: 301-585-6804
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1234
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: