Provider Demographics
NPI:1053757120
Name:JOHNSON, RICHARD MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:MICHAEL
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 1:9750 MIRAMAR RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4560
Mailing Address - Country:US
Mailing Address - Phone:858-566-5050
Mailing Address - Fax:
Practice Address - Street 1:9750 MIRAMAR RD
Practice Address - Street 2:SUITE 260
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4560
Practice Address - Country:US
Practice Address - Phone:858-566-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-16
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21904122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist