Provider Demographics
NPI:1508986027
Name:JOHNSON, JEFFREY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:D
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 N UNIVERSITY AVE
Mailing Address - Street 2:#6
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2654
Mailing Address - Country:US
Mailing Address - Phone:801-375-9511
Mailing Address - Fax:801-373-5537
Practice Address - Street 1:1275 N UNIVERSITY AVE STE 6
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2661
Practice Address - Country:US
Practice Address - Phone:801-375-9511
Practice Address - Fax:801-373-5537
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT144997-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice