Provider Demographics
NPI:1598883092
Name:JOHNSEN, ERIC MARTIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:MARTIN
Last Name:JOHNSEN
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 1:880 E MAIN RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:RI
Mailing Address - Zip Code:02871-2340
Mailing Address - Country:US
Mailing Address - Phone:401-683-5855
Mailing Address - Fax:401-683-5855
Practice Address - Street 1:880 E MAIN RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:RI
Practice Address - Zip Code:02871-2340
Practice Address - Country:US
Practice Address - Phone:401-683-5855
Practice Address - Fax:401-683-5855
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN 19451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIEJ01259Medicaid