Provider Demographics
NPI:1063512267
Name:ORVIS J. R. JOHNSON DDS,SC
Entity type:Organization
Organization Name:ORVIS J. R. JOHNSON DDS,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ORVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-923-0310
Mailing Address - Street 1:825 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54937-1365
Mailing Address - Country:US
Mailing Address - Phone:920-923-0310
Mailing Address - Fax:920-923-5335
Practice Address - Street 1:825 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NORTH FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54937-1365
Practice Address - Country:US
Practice Address - Phone:920-923-0310
Practice Address - Fax:920-923-5335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000785-015302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization