=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497956247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERETT R. JOHNSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 734 N MAIN ST
-----------------------------------------------------
City | LACONIA
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03246-2777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-524-8159
-----------------------------------------------------
Fax | 603-524-4506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 734 N MAIN ST
-----------------------------------------------------
City | LACONIA
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03246-2777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-524-8159
-----------------------------------------------------
Fax | 603-524-4506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. EVERETT ROGERS JOHNSON
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 603-524-8159
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 3129
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------