Basic Information
| Provider Information | |||||||||
| NPI: | 1942819248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JERRIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 304 N WATER ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176033374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172996371 | ||||||||
| FaxNumber: | 7179451587 | ||||||||
| Practice Location | |||||||||
| Address1: | 625 S DUKE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 176024509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172996371 | ||||||||
| FaxNumber: | 7177356518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2020 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS042775 | PA | Y | Dental Providers | Dentist |
No ID Information.