Provider Demographics
NPI:1073124103
Name:JOHNSON FAMILY DENTISTRY
Entity type:Organization
Organization Name:JOHNSON FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRZIBOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-381-7250
Mailing Address - Street 1:1617 E MILHAM AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-3049
Mailing Address - Country:US
Mailing Address - Phone:269-381-7250
Mailing Address - Fax:
Practice Address - Street 1:1617 E MILHAM AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-3049
Practice Address - Country:US
Practice Address - Phone:269-381-7250
Practice Address - Fax:269-381-7260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty