Provider Demographics
NPI:1598931974
Name:LAWRENCE G JOHANSON DDS, INC.
Entity Type:Organization
Organization Name:LAWRENCE G JOHANSON DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:GUNNAR
Authorized Official - Last Name:JOHANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-839-3227
Mailing Address - Street 1:PO BOX 2368
Mailing Address - Street 2:1661 PICKETT RD
Mailing Address - City:MCKINLEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95519-2368
Mailing Address - Country:US
Mailing Address - Phone:707-839-3227
Mailing Address - Fax:707-839-0844
Practice Address - Street 1:1661 PICKETT RD
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3914
Practice Address - Country:US
Practice Address - Phone:707-839-3227
Practice Address - Fax:707-839-0844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18244261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental