Provider Demographics
NPI:1588764856
Name:JOHNSON, CRAIG BRIAN (DDS)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:BRIAN
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:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:NISSWA
Mailing Address - State:MN
Mailing Address - Zip Code:56468
Mailing Address - Country:US
Mailing Address - Phone:218-963-2970
Mailing Address - Fax:218-963-9502
Practice Address - Street 1:25579 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NISSWA
Practice Address - State:MN
Practice Address - Zip Code:56468
Practice Address - Country:US
Practice Address - Phone:218-963-2970
Practice Address - Fax:218-963-9502
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11320122300000X
WY1003122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7479785OtherMINNESOTA STATE TAX