Provider Demographics
NPI:1942819248
Name:JOHNSON, JERRIN (DMD)
Entity Type:Individual
Prefix:
First Name:JERRIN
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 VAN FLEET CIR APT 207
Mailing Address - Street 2:
Mailing Address - City:SANATOGA
Mailing Address - State:PA
Mailing Address - Zip Code:19464-3339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2228 STATE HILL RD
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1904
Practice Address - Country:US
Practice Address - Phone:610-372-8406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS042775122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist