Provider Demographics
NPI:1518907658
Name:JOHNSON, PETER FINK (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:FINK
Last Name:JOHNSON
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 1:5565 GROSSMONT CENTER DR
Mailing Address - Street 2:SUITE 1-110
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3020
Mailing Address - Country:US
Mailing Address - Phone:619-463-1255
Mailing Address - Fax:619-463-1272
Practice Address - Street 1:5565 GROSSMONT CENTER DR
Practice Address - Street 2:SUITE 1-110
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3020
Practice Address - Country:US
Practice Address - Phone:619-463-1255
Practice Address - Fax:619-463-1272
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADS 255501223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC71227Medicare UPIN
CAD25550Medicare ID - Type Unspecified