Provider Demographics
NPI:1164543542
Name:JOHNSON, JEAN DOROTHY (DDS)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:DOROTHY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-3919
Mailing Address - Country:US
Mailing Address - Phone:570-759-8961
Mailing Address - Fax:570-759-6911
Practice Address - Street 1:807 E 4TH ST
Practice Address - Street 2:
Practice Address - City:BERWICK
Practice Address - State:PA
Practice Address - Zip Code:18603-3919
Practice Address - Country:US
Practice Address - Phone:570-759-8961
Practice Address - Fax:570-759-6911
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025468-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice