Provider Demographics
NPI:1427230770
Name:JOHNSON RANCH FAMILY DENTISTRY
Entity Type:Organization
Organization Name:JOHNSON RANCH FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:WALLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDSM , PC
Authorized Official - Phone:480-888-2271
Mailing Address - Street 1:270 E HUNT HWY
Mailing Address - Street 2:BLDG. 3, SUITE 14
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85243-4962
Mailing Address - Country:US
Mailing Address - Phone:480-888-2271
Mailing Address - Fax:480-888-7474
Practice Address - Street 1:270 E HUNT HWY
Practice Address - Street 2:BLDG. 3, SUITE 14
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85243-4962
Practice Address - Country:US
Practice Address - Phone:480-888-2271
Practice Address - Fax:480-888-7474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ58681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty