Provider Demographics
NPI:1295866804
Name:JOHANSON, S SHAUN (DDS)
Entity Type:Individual
Prefix:DR
First Name:S
Middle Name:SHAUN
Last Name:JOHANSON
Suffix:
Gender:M
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: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:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA408381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB40838-01OtherDENTICAL