MEDICARE: MALIEKA TRINEE JOHNSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	3361474	ID
2	1223D0001X	Public Health Dentistry	61342	CA
3	1223G0001X	General Practice Dentistry	61342	CA

General Provider Information

NPI Number	:	1003161969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MALIEKA TRINEE JOHNSON DDS

Provider Business Mailing Address
First Line	:	PO BOX 881496
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92168-1496
Country	:	US
Telephone Number	:	619-518-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4784 MUIR AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92107-2218
Country	:	US
Telephone Number	:	619-518-9000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/17/2012
Last Update Date	:	03/03/2025

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