Provider Demographics
NPI:1336141068
Name:JOHNSON, JOHN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
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 1:643 GOLD STAR HWY
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6267
Mailing Address - Country:US
Mailing Address - Phone:860-445-8569
Mailing Address - Fax:860-446-1890
Practice Address - Street 1:643 GOLD STAR HWY
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-6267
Practice Address - Country:US
Practice Address - Phone:860-445-8569
Practice Address - Fax:860-446-1890
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT68001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice