Provider Demographics
NPI:1376524819
Name:JOHNSON, MICHAEL BERNARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BERNARD
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 EDWARDS CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-2338
Mailing Address - Country:US
Mailing Address - Phone:925-962-0150
Mailing Address - Fax:925-962-0150
Practice Address - Street 1:1421 EDWARDS CT
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-2338
Practice Address - Country:US
Practice Address - Phone:925-962-0150
Practice Address - Fax:925-962-0150
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA192861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice