Provider Demographics
NPI:1083134480
Name:JOHNSON, JOSHUA W
Entity type:Individual
Prefix:
First Name:JOSHUA
Middle Name:W
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:USS TRIPOLI
Mailing Address - Street 2:BOX #3887
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96694-0000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2841 RENDOVA RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5490
Practice Address - Country:US
Practice Address - Phone:619-556-4157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty