MEDICARE: DR. STEPHEN JOHANSEN D.D.S., PC

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		UT

General Provider Information

NPI Number	:	1861685752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN JOHANSEN D.D.S., PC

Provider Business Mailing Address
First Line	:	7370 CREEK RD STE 202
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-6113
Country	:	US
Telephone Number	:	801-676-1234
Fax Number	:	801-676-5678

Provider Business Practice Location Address
First Line	:	7370 CREEK RD STE 202
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84093-6113
Country	:	US
Telephone Number	:	801-676-1234
Fax Number	:	801-676-5678

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

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	08/23/2007

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