Provider Demographics
NPI:1609820521
Name:JOHNSON, JOHN A (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
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 1:420 N. DIVISION ST.
Mailing Address - Street 2:P.O. BOX 188
Mailing Address - City:CRAIGMONT
Mailing Address - State:ID
Mailing Address - Zip Code:83523
Mailing Address - Country:US
Mailing Address - Phone:208-924-5830
Mailing Address - Fax:208-924-7516
Practice Address - Street 1:420 N DIVISION ST.
Practice Address - Street 2:
Practice Address - City:CRAIGMONT
Practice Address - State:ID
Practice Address - Zip Code:83523
Practice Address - Country:US
Practice Address - Phone:208-924-5830
Practice Address - Fax:208-924-7516
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD13881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0017744400Medicaid
ID836142OtherUNITED CONCORDIA TDP
ID1000932OtherREGENCE BLUE SHIELD
ID6201-8OtherBLUE CROSS