Provider Demographics
NPI:1215067442
Name:JOHNSON, JEFFREY L (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:JOHNSON
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 1:9197 GREENBACK LN STE C
Mailing Address - Street 2:
Mailing Address - City:ORANGEVALE
Mailing Address - State:CA
Mailing Address - Zip Code:95662-4792
Mailing Address - Country:US
Mailing Address - Phone:916-988-8890
Mailing Address - Fax:916-989-2187
Practice Address - Street 1:9197 GREENBACK LN STE C
Practice Address - Street 2:
Practice Address - City:ORANGEVALE
Practice Address - State:CA
Practice Address - Zip Code:95662-4792
Practice Address - Country:US
Practice Address - Phone:916-988-8890
Practice Address - Fax:916-989-2187
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADU284591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice