Provider Demographics
NPI:1417029158
Name:JOHNSON, BLAIR (DDS)
Entity Type:Individual
Prefix:DR
First Name:BLAIR
Middle Name:
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 1:1120 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6133
Mailing Address - Country:US
Mailing Address - Phone:715-834-8414
Mailing Address - Fax:715-834-3557
Practice Address - Street 1:1120 OAK RIDGE DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6133
Practice Address - Country:US
Practice Address - Phone:715-834-8414
Practice Address - Fax:715-834-3557
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44120151223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics