Provider Demographics
NPI:1225165889
Name:JOHNSON, DAVID W (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:W
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 1:3600 E STATE ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-1978
Mailing Address - Country:US
Mailing Address - Phone:815-399-6721
Mailing Address - Fax:
Practice Address - Street 1:3600 E STATE ST
Practice Address - Street 2:SUITE 206
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-1978
Practice Address - Country:US
Practice Address - Phone:815-399-6721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL018647-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice