Provider Demographics
NPI:1851559843
Name:JOHNSON, ERIC SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:SCOTT
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 1:647 CAMINO DE LOS MARES STE 209
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2807
Mailing Address - Country:US
Mailing Address - Phone:949-493-9311
Mailing Address - Fax:
Practice Address - Street 1:647 CAMINO DE LOS MARES STE 209
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2807
Practice Address - Country:US
Practice Address - Phone:949-493-9311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist