Provider Demographics
NPI:1073736674
Name:JOHNSON, MICHAEL ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ALAN
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 1:6204 W 300 S-1 # SOUTH-1
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:IN
Mailing Address - Zip Code:46714-9516
Mailing Address - Country:US
Mailing Address - Phone:260-565-4506
Mailing Address - Fax:
Practice Address - Street 1:447 E LINE ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IN
Practice Address - Zip Code:46740-8936
Practice Address - Country:US
Practice Address - Phone:260-368-7500
Practice Address - Fax:260-368-7167
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120104121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice