Provider Demographics
NPI:1154325017
Name:JOHNSON, DAVID WILLIAM JR (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WILLIAM
Last Name:JOHNSON
Suffix:JR
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 1:2900 CHICAGO AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1322
Mailing Address - Country:US
Mailing Address - Phone:612-823-2080
Mailing Address - Fax:612-823-5777
Practice Address - Street 1:2900 CHICAGO AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1322
Practice Address - Country:US
Practice Address - Phone:612-823-2080
Practice Address - Fax:612-823-5777
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN95121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice