Healthcare Provider Details

I. General information

NPI: 1841739836
Provider Name (Legal Business Name): GARRETT JOHANNSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2017
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 UNIVERSITY OF NEW MEXICO ALBUQUERQUE MSC 06-3500
ALBUQUERQUE NM
87131
US

IV. Provider business mailing address

1 UNIVERSITY OF NEW MEXICO ALBUQUERQUE MSC 06-3500
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-4031
  • Fax:
Mailing address:
  • Phone: 505-925-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number33228
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: