Provider Demographics
NPI:1518002260
Name:JOHNSON, EBENEZER (DDS FAGD)
Entity Type:Individual
Prefix:DR
First Name:EBENEZER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9645 MONTE VISTA AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:MONTCLAIR
Mailing Address - State:CA
Mailing Address - Zip Code:91763
Mailing Address - Country:US
Mailing Address - Phone:909-621-6002
Mailing Address - Fax:909-621-6634
Practice Address - Street 1:9645 MONTE VISTA AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:MONTCLAIR
Practice Address - State:CA
Practice Address - Zip Code:91763
Practice Address - Country:US
Practice Address - Phone:909-621-6002
Practice Address - Fax:909-621-6634
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD36088122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist