1811048507 NPI number — KEITH JOHNSON DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811048507 NPI number — KEITH JOHNSON DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KEITH JOHNSON DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ROSE DENTAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811048507
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/03/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2860 MICHELLE
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92606-1009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-508-3600
Provider Business Mailing Address Fax Number:
714-368-2092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2731 S ROSE AVENUE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-483-3658
Provider Business Practice Location Address Fax Number:
805-483-3696
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
KEITH
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER DOCTOR
Authorized Official Telephone Number:
805-483-3658

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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