Provider Demographics
NPI:1346815164
Name:JOHANSEN, ANDREW (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:JOHANSEN
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 1:4970 S 900 E STE B
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-5798
Mailing Address - Country:US
Mailing Address - Phone:801-261-2013
Mailing Address - Fax:
Practice Address - Street 1:4970 S 900 E STE B
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5798
Practice Address - Country:US
Practice Address - Phone:801-261-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12317484-9923122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist