Provider Demographics
NPI:1861460685
Name:JOHANSEN, KENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENT
Middle Name:
Last Name:JOHANSEN
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 1:3800 W RAY RD
Mailing Address - Street 2:#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:#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
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice