Provider Demographics
NPI:1588821052
Name:JOHNSON, PAUL W (DMD, PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:W
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8007 LAGUNA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7920
Mailing Address - Country:US
Mailing Address - Phone:916-691-6442
Mailing Address - Fax:916-691-6452
Practice Address - Street 1:8007 LAGUNA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7920
Practice Address - Country:US
Practice Address - Phone:916-691-6442
Practice Address - Fax:916-691-6452
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43798122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist