Provider Demographics
NPI:1306007737
Name:JOHNSON, BENJAMIN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:S
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 1:134 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DELAVAN
Mailing Address - State:WI
Mailing Address - Zip Code:53115-1802
Mailing Address - Country:US
Mailing Address - Phone:262-728-9330
Mailing Address - Fax:
Practice Address - Street 1:134 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DELAVAN
Practice Address - State:WI
Practice Address - Zip Code:53115-1802
Practice Address - Country:US
Practice Address - Phone:262-728-9330
Practice Address - Fax:262-728-0172
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6240-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist