Provider Demographics
NPI:1669675385
Name:JOHANSEN, ROBERT W (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
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 1:4777 TRAMWAY BLVD NE
Mailing Address - Street 2:APT 607
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2974
Mailing Address - Country:US
Mailing Address - Phone:614-425-1381
Mailing Address - Fax:
Practice Address - Street 1:5000 MENAUL BLVD NE STE B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-3046
Practice Address - Country:US
Practice Address - Phone:614-425-1381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50 0548931223X0400X
OH30.022825122300000X
CODEN.002020931223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist