Healthcare Provider Details

I. General information

NPI: 1063441434
Provider Name (Legal Business Name): GLENN DWIGHT JOHNSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DARTMOUTH-HITCHCOCK MEDICAL CENTER ONE MEDICAL CENTER DRIVE
LEBANON NH
03756-0001
US

IV. Provider business mailing address

DARTMOUTH-HITCHCOCK MEDICAL CENTER ONE MEDICAL CENTER DRIVE
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-8124
  • Fax: 603-650-7898
Mailing address:
  • Phone: 603-650-8124
  • Fax: 603-650-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number6028
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: