Healthcare Provider Details

I. General information

NPI: 1457754004
Provider Name (Legal Business Name): CALEB JOHNSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2014
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S OSAGE AVE
TIPTON MO
65081-8470
US

IV. Provider business mailing address

3816 NW 75TH ST
KANSAS CITY MO
64151-4247
US

V. Phone/Fax

Practice location:
  • Phone: 660-433-5741
  • Fax:
Mailing address:
  • Phone: 816-541-1897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2019014269
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: