Active NPI
Kenneth Johannesen, DDS
- Dentist
- Northport, NY
National Provider Identifier
1477507754
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 044235
- Practice address
- 79 Middleville Rd
Dvamc Northport (160)
Northport, NY 11768-2200 - Phone
- (631) 266-6057
- Fax
- (631) 266-6020
- NPI assigned
- May 20, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 044235 | NY | Primary |
Addresses
Primary practice location
79 Middleville Rd
Dvamc Northport (160)
Northport, NY 11768-2200
Mailing address
79 Middleville Rd
Northport, NY 11768-2200
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in NY
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20110512000656 | NY | Order and Referring Only - Oral Surgery | 8527244383 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1148083200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1184198400000",
"number": "1477507754",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "79 MIDDLEVILLE RD",
"city": "NORTHPORT",
"state": "NY",
"postal_code": "117682200"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "79 MIDDLEVILLE RD",
"address_2": "DVAMC NORTHPORT (160)",
"city": "NORTHPORT",
"state": "NY",
"postal_code": "117682200",
"telephone_number": "631-266-6057",
"fax_number": "631-266-6020"
}
],
"practiceLocations": [],
"basic": {
"last_name": "JOHANNESEN",
"first_name": "KENNETH",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-05-20",
"last_updated": "2007-07-12",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NY",
"license": "044235",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Northport, NY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 12, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.