Provider Demographics
NPI:1003947623
Name:S. SHAUN JOHANSON DDS, INC.
Entity Type:Organization
Organization Name:S. SHAUN JOHANSON DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:S
Authorized Official - Middle Name:SHAUN
Authorized Official - Last Name:JOHANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-839-3227
Mailing Address - Street 1:PO BOX 2368
Mailing Address - Street 2:
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-2368
Mailing Address - Country:US
Mailing Address - Phone:707-839-3227
Mailing Address - Fax:
Practice Address - Street 1:1661 PICKETT RD
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3914
Practice Address - Country:US
Practice Address - Phone:707-839-3227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA408381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB40838-01OtherDENTICAL