Provider Demographics
NPI:1073780128
Name:DRS EBENEZER & RACHEL JOHNSON DDS INC
Entity Type:Organization
Organization Name:DRS EBENEZER & RACHEL JOHNSON DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-621-6002
Mailing Address - Street 1:9645 MONTE VISTA AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763
Mailing Address - Country:US
Mailing Address - Phone:909-621-6002
Mailing Address - Fax:909-621-6634
Practice Address - Street 1:9645 MONTE VISTA AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763
Practice Address - Country:US
Practice Address - Phone:909-621-6002
Practice Address - Fax:909-621-6002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD36088122300000X
CAD37238122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty