Healthcare Provider Details

I. General information

NPI: 1730170457
Provider Name (Legal Business Name): SHARON A DISTANT JOHNSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BLONDELL AVE
BRONX NY
10461-2660
US

IV. Provider business mailing address

241 CLAREMONT AVE
MT VERNON NY
10552-3305
US

V. Phone/Fax

Practice location:
  • Phone: 718-405-8197
  • Fax:
Mailing address:
  • Phone: 914-374-6741
  • Fax: 718-994-1308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number047401
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: