Provider Demographics
NPI:1457486391
Name:DR. R. W. JOHNSON, P.A.
Entity Type:Organization
Organization Name:DR. R. W. JOHNSON, P.A.
Other - Org Name:DENTAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:W
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-532-2233
Mailing Address - Street 1:304 W LYON ST
Mailing Address - Street 2:P. O. BOX 448
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1308
Mailing Address - Country:US
Mailing Address - Phone:507-532-2233
Mailing Address - Fax:507-532-2234
Practice Address - Street 1:304 W LYON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1308
Practice Address - Country:US
Practice Address - Phone:507-532-2233
Practice Address - Fax:507-532-2234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND7816122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty