Healthcare Provider Details

I. General information

NPI: 1366571200
Provider Name (Legal Business Name): DOUGLAS SCOTT JOHANSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57418 COUNTY ROAD 681
HARTFORD MI
49057-9421
US

IV. Provider business mailing address

2611 S CLEVELAND AVE
SAINT JOSEPH MI
49085-3001
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-3143
  • Fax:
Mailing address:
  • Phone: 269-408-1225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901018068
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: