Provider Demographics
NPI:1316416621
Name:J. GRANT JOHANSEN DMD PLLC
Entity Type:Organization
Organization Name:J. GRANT JOHANSEN DMD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:GRANT
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MPH
Authorized Official - Phone:480-254-6712
Mailing Address - Street 1:3800 W RAY RD STE 11
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-5940
Mailing Address - Country:US
Mailing Address - Phone:480-345-0530
Mailing Address - Fax:480-345-0048
Practice Address - Street 1:3800 W RAY RD STE 11
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-5940
Practice Address - Country:US
Practice Address - Phone:480-345-0530
Practice Address - Fax:480-345-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental