Provider Demographics
NPI:1164633061
Name:JOHNSON, ROGER C (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:C
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 1:503 3RD STREET
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-3015
Mailing Address - Country:US
Mailing Address - Phone:701-662-4961
Mailing Address - Fax:
Practice Address - Street 1:503 3RD ST NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-3015
Practice Address - Country:US
Practice Address - Phone:701-662-4961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDND1574122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist