Provider Demographics
NPI:1407915291
Name:JOHNSON, TODD A (DMD)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 MEMORIAL CT
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-6502
Mailing Address - Country:US
Mailing Address - Phone:715-496-1128
Mailing Address - Fax:715-972-8123
Practice Address - Street 1:5702 MEMORIAL CT
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-6502
Practice Address - Country:US
Practice Address - Phone:715-496-1128
Practice Address - Fax:715-972-8123
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190255111223G0001X
WI10014831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1004971Medicaid