Provider Demographics
NPI:1386779072
Name:JOHNSON, MELISSA MARY (RDH)
Entity type:Individual
Prefix:MS
First Name:MELISSA
Middle Name:MARY
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 1:1300 SAN JOSE PLACE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303
Mailing Address - Country:US
Mailing Address - Phone:715-923-4148
Mailing Address - Fax:
Practice Address - Street 1:1711 SHAWNO AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303
Practice Address - Country:US
Practice Address - Phone:920-494-9541
Practice Address - Fax:920-494-8195
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6901016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist