Provider Demographics
NPI:1144230566
Name:JOHNSON, NEAL (DMD)
Entity Type:Individual
Prefix:
First Name:NEAL
Middle Name:
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 1:115 W 100 S
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-9125
Mailing Address - Country:US
Mailing Address - Phone:208-436-4532
Mailing Address - Fax:208-436-0347
Practice Address - Street 1:115 W 100 S
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-9125
Practice Address - Country:US
Practice Address - Phone:208-436-4532
Practice Address - Fax:208-436-0347
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD39031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice