MEDICARE: JERRY ALAN 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	33106	CA

General Provider Information

NPI Number	:	1871584565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRY ALAN JOHNSON D.D.S.

Provider Business Mailing Address
First Line	:	2295 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-1944
Country	:	US
Telephone Number	:	626-798-7896
Fax Number	:

Provider Business Practice Location Address
First Line	:	2295 E WASHINGTON BLVD
Second Line	:
City	:	PASADENA
State	:	CA
Zip	:	91104-1944
Country	:	US
Telephone Number	:	626-798-7896
Fax Number	:

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	07/08/2007

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