MEDICARE: DOUGLAS D. 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DG27003	CA

General Provider Information

NPI Number	:	1558528505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS D. JOHNSON D.D.S.

Provider Business Mailing Address
First Line	:	1310 TARA HILLS DR STE G
Second Line	:
City	:	PINOLE
State	:	CA
Zip	:	94564-2533
Country	:	US
Telephone Number	:	510-724-0777
Fax Number	:	510-724-0704

Provider Business Practice Location Address
First Line	:	1310 TARA HILLS DR STE G
Second Line	:
City	:	PINOLE
State	:	CA
Zip	:	94564-2533
Country	:	US
Telephone Number	:	510-724-0777
Fax Number	:	510-724-0704

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

Provider Enumeration Date	:	05/19/2008
Last Update Date	:	05/19/2008

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Directions to “ DOUGLAS D. JOHNSON D.D.S.” Practice Location

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