MEDICARE: DR. KENT MAX 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	1223G0001X	General Practice Dentistry	1434409921	UT

General Provider Information

NPI Number	:	1679662837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENT MAX JOHNSON DDS

Provider Business Mailing Address
First Line	:	1840 SUN PEAK DR
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-6732
Country	:	US
Telephone Number	:	435-658-0678
Fax Number	:	435-940-1385

Provider Business Practice Location Address
First Line	:	1840 SUN PEAK DR
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-6732
Country	:	US
Telephone Number	:	435-658-0678
Fax Number	:	435-940-1385

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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