Provider Demographics
NPI:1275603268
Name:JOHNSON, DINA K
Entity Type:Individual
Prefix:
First Name:DINA
Middle Name:K
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DINA
Other - Middle Name:K
Other - Last Name:O'DONNELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3885
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:760-414-3885
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist