Provider Demographics
NPI:1205360088
Name:JOHNSON, MICHELE DAWN (RDHAP)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:DAWN
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 903
Mailing Address - Street 2:520 GREENWOOD AVE.
Mailing Address - City:BLUE LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95525-0903
Mailing Address - Country:US
Mailing Address - Phone:707-668-5683
Mailing Address - Fax:707-845-0088
Practice Address - Street 1:520 GREENWOOD AVE.
Practice Address - Street 2:
Practice Address - City:BLUE LAKE
Practice Address - State:CA
Practice Address - Zip Code:95525-0903
Practice Address - Country:US
Practice Address - Phone:707-668-5683
Practice Address - Fax:707-845-0088
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA654124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist