Provider Demographics
NPI:1023045341
Name:JOHNSON, KIRBY CHARLES (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIRBY
Middle Name:CHARLES
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 1:320 CALAMUS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55340
Mailing Address - Country:US
Mailing Address - Phone:612-788-9246
Mailing Address - Fax:612-788-5511
Practice Address - Street 1:3905 SILVER LAKE RD
Practice Address - Street 2:
Practice Address - City:ST ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55421
Practice Address - Country:US
Practice Address - Phone:612-788-9246
Practice Address - Fax:612-788-5511
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10472DDS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
T93145Medicare UPIN