Provider Demographics
NPI:1821114778
Name:KENT JOHANSEN, DDS, PLC
Entity Type:Organization
Organization Name:KENT JOHANSEN, DDS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENT
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:480-345-0530
Mailing Address - Street 1:3800 W RAY RD
Mailing Address - Street 2:SUITE 11
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-5940
Mailing Address - Country:US
Mailing Address - Phone:480-345-0530
Mailing Address - Fax:480-345-0048
Practice Address - Street 1:3800 W RAY RD
Practice Address - Street 2:SUITE 11
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85226-5940
Practice Address - Country:US
Practice Address - Phone:480-345-0530
Practice Address - Fax:480-345-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty