MEDICARE: DR. ERIC ROBERT JOHNSON D.D.S.

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	1223G0001X	General Practice Dentistry		IL

General Provider Information

NPI Number	:	1285640391
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ERIC ROBERT JOHNSON D.D.S.

Provider Business Mailing Address
First Line	:	215 W. 75TH ST
Second Line	:
City	:	WILLOWBROOK
State	:	IL
Zip	:	60527
Country	:	US
Telephone Number	:	630-920-9841
Fax Number	:

Provider Business Practice Location Address
First Line	:	3637 W 83RD PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60652-3203
Country	:	US
Telephone Number	:	773-767-4030
Fax Number	:	773-767-4031

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	07/08/2007

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