Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 56144 | CA |
Y | 1223D0004X | Dentist Anesthesiologist | 1498 | CA |
NPI | 1831334929 |
---|---|
Provider Name | Tyler Johnson |
First Address | Carlsbad, CA 92008-1950 |
Second Address | Carlsbad, CA 92008-1950 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/12/2008 |
Last Update Date | 25/06/2019 |