Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 2901600392 | MI |
N | 1223G0001X | General Practice | 2901600392 | MI |
N | 213EG0000X | General Practice | 2901600392 | MI |
NPI | 1003449265 |
---|---|
Provider Name | Shon Johnson |
First Address | Southfield, MI 48076-1740 |
Second Address | Taylor, MI 48180-2365 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2020 |
Last Update Date | 17/02/2020 |