Provider Demographics
NPI:1093704124
Name:JOHNSON, CHRISTOPHER M (DDS)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
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 1:10511 E RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55347-4918
Mailing Address - Country:US
Mailing Address - Phone:952-941-9007
Mailing Address - Fax:
Practice Address - Street 1:425 2ND ST
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-2038
Practice Address - Country:US
Practice Address - Phone:952-474-6133
Practice Address - Fax:952-474-7361
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND110611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN020998800OtherMN CARE ID