Provider Demographics
NPI:1477877116
Name:ERIC JOHNSON DDS, INC., A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:ERIC JOHNSON DDS, INC., A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:OLIN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-540-8800
Mailing Address - Street 1:4201 TORRANCE BLVD
Mailing Address - Street 2:SUITE 420
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4504
Mailing Address - Country:US
Mailing Address - Phone:310-540-8800
Mailing Address - Fax:310-540-8802
Practice Address - Street 1:4201 TORRANCE BLVD
Practice Address - Street 2:SUITE 420
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4504
Practice Address - Country:US
Practice Address - Phone:310-540-8800
Practice Address - Fax:310-540-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34125261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6355110001Medicare NSC