Provider Demographics
NPI:1386830065
Name:JOHNSON, THOMAS G (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
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 1:700 CEDAR ST STE 44
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-1787
Mailing Address - Country:US
Mailing Address - Phone:320-815-5711
Mailing Address - Fax:
Practice Address - Street 1:700 CEDAR ST STE 44
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1787
Practice Address - Country:US
Practice Address - Phone:320-815-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-17
Last Update Date:2007-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND72091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice