=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003947623
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S. SHAUN JOHANSON DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1661 PICKETT RD
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-839-3227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2368
-----------------------------------------------------
City | MCKINLEYVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95519-2368
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-839-3227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. S SHAUN JOHANSON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 707-839-3227
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 40838
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------