Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | DS018565L | PA |
NPI | 1003961657 |
---|---|
Provider Name | Dr. Eric Mathias Johnsen JR. |
First Address | York, PA 17403-3676 |
Second Address | York, PA 17403-3676 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0518577 | (05) | PA |