Provider Demographics
NPI:1497081459
Name:VIP SMILES JOHNSON DENTAL INC
Entity Type:Organization
Organization Name:VIP SMILES JOHNSON DENTAL INC
Other - Org Name:VIP SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:216-288-7560
Mailing Address - Street 1:5260 WARRENSVILLE CTR RD
Mailing Address - Street 2:
Mailing Address - City:MAPLE HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44137-1913
Mailing Address - Country:US
Mailing Address - Phone:216-475-0080
Mailing Address - Fax:216-475-0778
Practice Address - Street 1:5260 WARRENSVILLE CTR RD
Practice Address - Street 2:
Practice Address - City:MAPLE HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44137-1913
Practice Address - Country:US
Practice Address - Phone:216-475-0080
Practice Address - Fax:216-475-0778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-219171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2492440Medicaid