Basic Information
Provider Information
NPI: 1548447733
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JOHNSON
FirstName: JANICE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: RDH
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 150 TEJAS PL
Address2: PO BOX 430
City: NIPOMO
State: CA
PostalCode: 934449123
CountryCode: US
TelephoneNumber: 8059293211
FaxNumber: 8059296440
Practice Location
Address1: 1050 LAS TABLAS RD
Address2: STE 17
City: TEMPLETON
State: CA
PostalCode: 934659729
CountryCode: US
TelephoneNumber: 8054342020
FaxNumber: 8054342911
Other Information
ProviderEnumerationDate: 01/30/2008
LastUpdateDate: 01/30/2008
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
124Q00000X17350CAY Dental ProvidersDental Hygienist 

No ID Information.


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