Provider Demographics
NPI:1952529133
Name:JOHNSON, KEITH E
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:E
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13270 BIG BASIN WAY
Mailing Address - Street 2:
Mailing Address - City:BOULDER CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:95006
Mailing Address - Country:US
Mailing Address - Phone:831-338-2131
Mailing Address - Fax:831-338-2183
Practice Address - Street 1:13270 BIG BASIN WAY
Practice Address - Street 2:
Practice Address - City:BOULDER CREEK
Practice Address - State:CA
Practice Address - Zip Code:95006
Practice Address - Country:US
Practice Address - Phone:831-338-2131
Practice Address - Fax:831-338-2183
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA421621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice