Provider Demographics
NPI:1073860854
Name:JOHNSON, MICHAEL C (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:C
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 LAKE ST # 1000
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-1903
Mailing Address - Country:US
Mailing Address - Phone:801-471-8311
Mailing Address - Fax:
Practice Address - Street 1:540 LAKE ST # 1000
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-1903
Practice Address - Country:US
Practice Address - Phone:801-471-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-10
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE606423831223S0112X
MND145011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery