Healthcare Provider Details

I. General information

NPI: 1386625341
Provider Name (Legal Business Name): BERNARD JOSEPH JOHNSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

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

III. Provider practice location address

4368 DRESSLER RD NW
CANTON OH
44718-2771
US

IV. Provider business mailing address

4368 DRESSLER RD NW
CANTON OH
44718-2771
US

V. Phone/Fax

Practice location:
  • Phone: 330-493-4242
  • Fax: 330-493-1303
Mailing address:
  • Phone: 330-493-4242
  • Fax: 330-493-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13689
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: