Provider Demographics
NPI:1245395839
Name:JOHNSON, ROSS M (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:M
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 1:840 S FAIRMONT AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5105
Mailing Address - Country:US
Mailing Address - Phone:209-369-6703
Mailing Address - Fax:
Practice Address - Street 1:840 S FAIRMONT AVE STE 2
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5105
Practice Address - Country:US
Practice Address - Phone:209-369-6703
Practice Address - Fax:209-369-6798
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist