Provider Demographics
NPI:1639575855
Name:JOHNSON, DOUG
Entity Type:Individual
Prefix:DR
First Name:DOUG
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2920 SILVER OAK TRL
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-9225
Mailing Address - Country:US
Mailing Address - Phone:319-360-8255
Mailing Address - Fax:
Practice Address - Street 1:2080 CENTURY PARK E
Practice Address - Street 2:SUITE 1601
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2001
Practice Address - Country:US
Practice Address - Phone:310-277-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-16
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist