Provider Demographics
NPI:1992780746
Name:JOHNSON, JAY WILSON I (DDS)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:WILSON
Last Name:JOHNSON
Suffix:I
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:PO BOX 555221
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5221
Mailing Address - Country:US
Mailing Address - Phone:760-725-5102
Mailing Address - Fax:
Practice Address - Street 1:BLDG H 2005 KNIGHT LANE
Practice Address - Street 2:NAVY MEDICINE SUPPORT COMMAND ATTN: MEDICAL STAFF SVCS
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32212-0140
Practice Address - Country:US
Practice Address - Phone:760-725-5102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007800A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice