Provider Demographics
NPI:1780643957
Name:JOHNSON, DONALD EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:EDWARD
Last Name:JOHNSON
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 1:8325 CITY CENTRE DRIVE
Mailing Address - Street 2:#125
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125
Mailing Address - Country:US
Mailing Address - Phone:651-731-8424
Mailing Address - Fax:651-731-0917
Practice Address - Street 1:8325 CITY CENTRE DRIVE
Practice Address - Street 2:#125
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125
Practice Address - Country:US
Practice Address - Phone:651-731-8424
Practice Address - Fax:651-731-0917
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7905122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist