Healthcare Provider Details

I. General information

NPI: 1629601679
Provider Name (Legal Business Name): ROBERT JACKSON JOHNSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2020
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2508
US

IV. Provider business mailing address

947 N 50 E
KAYSVILLE UT
84037-1203
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number4405-23
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberD012025
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number11770
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: