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General NPI Number Information
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NPI Number | 1316416621
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Entity Type | Organization
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Legal Business Name | J. GRANT JOHANSEN DMD PLLC
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Dates
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Enumeration Date | 11/15/2018
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Last Update Date | 11/15/2018
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Provider Practice Location Address
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Address Line | 3800 W RAY RD STE 11
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City | CHANDLER
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State | AZ
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Zip | 85226-5940
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Country | US
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Telephone | 480-345-0530
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Fax | 480-345-0048
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Provider Business Mailing Address
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Address Line | 3800 W RAY RD STE 11
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City | CHANDLER
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State | AZ
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Zip | 85226-5940
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Country | US
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Telephone | 480-345-0530
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Fax | 480-345-0048
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Authorized Official
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Title or Position | DENTIST, OWNER
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Name | DR. JUSTIN GRANT JOHANSEN
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Credential | DMD, MPH
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Telephone | 480-254-6712
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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