Provider Demographics
NPI:1679771174
Name:JOHNSON, MALIA LYNN (DDS)
Entity type:Individual
Prefix:
First Name:MALIA
Middle Name:LYNN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 TEJAS PL
Mailing Address - Street 2:PO BOX 430
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9123
Mailing Address - Country:US
Mailing Address - Phone:805-931-2556
Mailing Address - Fax:805-929-6440
Practice Address - Street 1:150 TEJAS PL
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9123
Practice Address - Country:US
Practice Address - Phone:805-929-3254
Practice Address - Fax:805-929-6440
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54498122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist