Provider Demographics
NPI:1114068616
Name:JOHNSEN, BROCK ALLEN (DDS)
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:ALLEN
Last Name:JOHNSEN
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 1:4140 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:MI
Mailing Address - Zip Code:49455
Mailing Address - Country:US
Mailing Address - Phone:231-861-4858
Mailing Address - Fax:
Practice Address - Street 1:4140 W SHELBY RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:MI
Practice Address - Zip Code:49455-9660
Practice Address - Country:US
Practice Address - Phone:231-861-4858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist