Provider Demographics
NPI:1225124571
Name:JOHNSON CREEK DENTAL
Entity Type:Organization
Organization Name:JOHNSON CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHATHON
Authorized Official - Middle Name:J
Authorized Official - Last Name:MELK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:920-690-2554
Mailing Address - Street 1:540 VILLAGE WALK LANE
Mailing Address - Street 2:SUITE E
Mailing Address - City:JOHNSON CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53038
Mailing Address - Country:US
Mailing Address - Phone:920-699-2554
Mailing Address - Fax:920-699-3059
Practice Address - Street 1:540 VILLAGE WALK LANE
Practice Address - Street 2:SUITE E
Practice Address - City:JOHNSON CREEK
Practice Address - State:WI
Practice Address - Zip Code:53038
Practice Address - Country:US
Practice Address - Phone:920-699-2554
Practice Address - Fax:920-699-3059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty