Provider Demographics
NPI:1568589208
Name:JOHNSON, RAYMONT HERBERT JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAYMONT
Middle Name:HERBERT
Last Name:JOHNSON
Suffix:JR
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 1:808 E MANCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1914
Mailing Address - Country:US
Mailing Address - Phone:310-671-1234
Mailing Address - Fax:310-677-8853
Practice Address - Street 1:808 E MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1914
Practice Address - Country:US
Practice Address - Phone:310-671-1234
Practice Address - Fax:310-677-8853
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953877361OtherTAX PAYER ID
CA025404OtherMEDICAL ID