Provider Demographics
NPI:1467867895
Name:JOHNSON, WESLEY
Entity type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12897 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:ND
Mailing Address - Zip Code:58054-9707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10110 SOUTH 7650 EAST
Practice Address - Street 2:
Practice Address - City:CROW AGENCY
Practice Address - State:MT
Practice Address - Zip Code:59022
Practice Address - Country:US
Practice Address - Phone:406-638-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-24
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13407122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist