Healthcare Provider Details

I. General information

NPI: 1750353686
Provider Name (Legal Business Name): SUSAN DEANA JOHNSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2006
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR NAVAL MEDICAL CENTER PORTSMOUTH
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

3994 NORTON PL
FAIRFAX VA
22030-3734
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5000
  • Fax:
Mailing address:
  • Phone: 757-339-2950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD11173
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: