Provider Demographics
NPI:1942859590
Name:JOHNSON, SHEVANTHI REBEKAH (DDS)
Entity Type:Individual
Prefix:
First Name:SHEVANTHI
Middle Name:REBEKAH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 QUIET SLOPE DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2021
Mailing Address - Country:US
Mailing Address - Phone:619-727-3444
Mailing Address - Fax:
Practice Address - Street 1:5208 JACKSON DR STE 108
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-7902
Practice Address - Country:US
Practice Address - Phone:619-466-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist