Provider Demographics
NPI:1962563874
Name:JOHNSON, TERESA EVELYN (DDS, MS, MPH, FASGD)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:EVELYN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS, MS, MPH, FASGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 DREW AVE SE
Mailing Address - Street 2:
Mailing Address - City:MADELIA
Mailing Address - State:MN
Mailing Address - Zip Code:56062-1841
Mailing Address - Country:US
Mailing Address - Phone:507-642-8742
Mailing Address - Fax:507-642-2926
Practice Address - Street 1:115 DREW AVE SE
Practice Address - Street 2:
Practice Address - City:MADELIA
Practice Address - State:MN
Practice Address - Zip Code:56062-1841
Practice Address - Country:US
Practice Address - Phone:507-642-8742
Practice Address - Fax:507-642-2926
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND100711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN503822700Medicaid