Basic Information
| Provider Information | |||||||||
| NPI: | 1184933020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 81 W ESPERANZA BLVD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856142667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206254401 | ||||||||
| FaxNumber: | 5206258504 | ||||||||
| Practice Location | |||||||||
| Address1: | 81 W ESPERANZA BLVD | ||||||||
| Address2: | STE 201 | ||||||||
| City: | GREEN VALLEY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 856142667 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5206254401 | ||||||||
| FaxNumber: | 5206258504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2010 | ||||||||
| LastUpdateDate: | 09/27/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2741 | AZ | Y | Dental Providers | Dentist | General Practice |
No ID Information.