Provider Demographics
NPI:1144788274
Name:JOHNSON, ROBERT SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:SCOTT
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 1:314 W. MAIN ST.
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53094
Mailing Address - Country:US
Mailing Address - Phone:920-261-1140
Mailing Address - Fax:
Practice Address - Street 1:314 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53094
Practice Address - Country:US
Practice Address - Phone:920-261-1140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5000914-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty