Provider Demographics
NPI:1437200615
Name:JOHNSON, LAURA MICHELLE (DDS)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:MICHELLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1002 RAMSEY AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-5816
Mailing Address - Country:US
Mailing Address - Phone:541-476-2200
Mailing Address - Fax:541-956-0329
Practice Address - Street 1:1002 RAMSEY AVE
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5816
Practice Address - Country:US
Practice Address - Phone:541-476-2200
Practice Address - Fax:541-956-0329
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD76471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice