Healthcare Provider Details

I. General information

NPI: 1457484115
Provider Name (Legal Business Name): ROGER EDMUND JOHANSEN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST NJDS ROOM D 837
NEWARK NJ
07103-2495
US

IV. Provider business mailing address

518 GREGORY AVE A-105
WEEHAWKEN NJ
07086-5706
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-4526
  • Fax:
Mailing address:
  • Phone: 201-920-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number14977
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: