Provider Demographics
NPI:1992857510
Name:JOHANSEN, STEPHEN P (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:P
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 1:1612 HUGUENOT ROAD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113
Mailing Address - Country:US
Mailing Address - Phone:804-794-9789
Mailing Address - Fax:804-794-9762
Practice Address - Street 1:6441 IRONBRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23113
Practice Address - Country:US
Practice Address - Phone:804-743-8166
Practice Address - Fax:804-743-4818
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005877122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist