Provider Demographics
NPI:1902930050
Name:JOHNSON, DAVID R (DDS,SC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS,SC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:BRILLION
Mailing Address - State:WI
Mailing Address - Zip Code:54110-1435
Mailing Address - Country:US
Mailing Address - Phone:920-756-5339
Mailing Address - Fax:920-756-5319
Practice Address - Street 1:544 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:BRILLION
Practice Address - State:WI
Practice Address - Zip Code:54110-1435
Practice Address - Country:US
Practice Address - Phone:920-756-5339
Practice Address - Fax:920-756-5319
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2041G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice