Provider Demographics
NPI:1306328109
Name:JOHNSON, ELIZABETH RUTH (RDH)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:RUTH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4830 FOX CRK E APT 114
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-4935
Mailing Address - Country:US
Mailing Address - Phone:765-461-1713
Mailing Address - Fax:
Practice Address - Street 1:38865 DEQUINDRE RD STE 105
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-6812
Practice Address - Country:US
Practice Address - Phone:248-879-7756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902018576124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist