Provider Demographics
NPI:1639251721
Name:JOHNSON, EDWARD S (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:S
Last Name:JOHNSON
Suffix:
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 1:500 BLUE HILLS AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1500
Mailing Address - Country:US
Mailing Address - Phone:860-714-2111
Mailing Address - Fax:860-714-8528
Practice Address - Street 1:500 BLUE HILLS AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1500
Practice Address - Country:US
Practice Address - Phone:860-714-2111
Practice Address - Fax:860-714-8528
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT39601223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery