Provider Demographics
NPI:1316975568
Name:JOHNSON, JERRY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:LEE
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 1:29847 260TH ST
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-6365
Mailing Address - Country:US
Mailing Address - Phone:507-376-9253
Mailing Address - Fax:
Practice Address - Street 1:1316 MCMILLAN ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1646
Practice Address - Country:US
Practice Address - Phone:507-376-5525
Practice Address - Fax:507-376-3796
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN101851223G0001X
IA70921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10185OtherDELTA
IA176K2JOOtherBCBS
820-685OtherUNITED CONCORDIA
IA0964114OtherDELTA
MN46482JOOtherBCBS
MN687623400Medicaid