Provider Demographics
NPI:1366571200
Name:JOHANSEN, DOUGLAS SCOTT (DDS)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:SCOTT
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 1:2611 S CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3001
Mailing Address - Country:US
Mailing Address - Phone:269-408-1225
Mailing Address - Fax:
Practice Address - Street 1:57418 COUNTY ROAD 681
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:MI
Practice Address - Zip Code:49057-9421
Practice Address - Country:US
Practice Address - Phone:269-621-3143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018068122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist