=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942859590
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEVANTHI REBEKAH JOHNSON DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2019
-----------------------------------------------------
Last Update Date | 09/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5208 JACKSON DR STE 108
-----------------------------------------------------
City | LA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91942-7902
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-466-4448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5930 QUIET SLOPE DR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92120-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-727-3444
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 103973
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------