Provider Demographics
NPI:1104999069
Name:JOHNSON, ROBERT J (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:J
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 1:400 LAKE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:ONTONAGON
Mailing Address - State:MI
Mailing Address - Zip Code:49953-1034
Mailing Address - Country:US
Mailing Address - Phone:906-884-4040
Mailing Address - Fax:906-884-4080
Practice Address - Street 1:400 LAKE ST
Practice Address - Street 2:STE 101
Practice Address - City:ONTONAGON
Practice Address - State:MI
Practice Address - Zip Code:49953-1034
Practice Address - Country:US
Practice Address - Phone:906-884-4040
Practice Address - Fax:906-884-4080
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010092421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1704352Medicaid