Basic Information
| Provider Information | |||||||||
| NPI: | 1760498778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2405 CHAMBERSBURG AVE | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182691189 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | FOND DU LAC HUMAN SERVICES DIVISION | ||||||||
| Address2: | 927 TRETTLE LANE | ||||||||
| City: | CLOQUET | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188791227 | ||||||||
| FaxNumber: | 2188782188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D12266 | MN | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | BJ9870305 | 01 | MN | DEA | OTHER |