Provider Demographics
NPI:1043378177
Name:JOHANSEN, NELSON ALEXANDER (DDS)
Entity type:Individual
Prefix:DR
First Name:NELSON
Middle Name:ALEXANDER
Last Name:JOHANSEN
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 1:1204 COTTONWOOD STREET
Mailing Address - Street 2:3
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695
Mailing Address - Country:US
Mailing Address - Phone:530-662-8736
Mailing Address - Fax:530-662-8736
Practice Address - Street 1:1204 COTTONWOOD STREET
Practice Address - Street 2:3
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695
Practice Address - Country:US
Practice Address - Phone:530-662-8736
Practice Address - Fax:530-662-0127
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA367721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice