Provider Demographics
NPI:1245589530
Name:JOHNSON, MICHELLE (DDS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 WILSON AVE SW
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52404-6342
Mailing Address - Country:US
Mailing Address - Phone:319-396-0700
Mailing Address - Fax:
Practice Address - Street 1:4135 WILSON AVE SW
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52404-6342
Practice Address - Country:US
Practice Address - Phone:319-396-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-03
Last Update Date:2012-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice