MEDICARE: DR. ANDREW JOHANSEN 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	12317484-9923	UT

General Provider Information

NPI Number	:	1346815164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANDREW JOHANSEN DDS

Provider Business Mailing Address
First Line	:	4970 S 900 E STE B
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-5798
Country	:	US
Telephone Number	:	801-261-2013
Fax Number	:

Provider Business Practice Location Address
First Line	:	4970 S 900 E STE B
Second Line	:
City	:	HOLLADAY
State	:	UT
Zip	:	84117-5798
Country	:	US
Telephone Number	:	801-261-2013
Fax Number	:

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

Provider Enumeration Date	:	05/24/2021
Last Update Date	:	05/24/2021

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