Provider Demographics
NPI:1457484115
Name:JOHANSEN, ROGER EDMUND (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:EDMUND
Last Name:JOHANSEN
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 1:518 GREGORY AVE
Mailing Address - Street 2:A-105
Mailing Address - City:WEEHAWKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07086-5706
Mailing Address - Country:US
Mailing Address - Phone:201-920-9026
Mailing Address - Fax:
Practice Address - Street 1:110 BERGEN ST
Practice Address - Street 2:NJDS ROOM D 837
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2495
Practice Address - Country:US
Practice Address - Phone:973-972-4526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ149771223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics