Provider Demographics
NPI:1457631517
Name:JOHNSON, NEIL JAMES (DDS, PHD)
Entity Type:Individual
Prefix:DR
First Name:NEIL
Middle Name:JAMES
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:DDS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4236 BEARD AVE N
Mailing Address - Street 2:
Mailing Address - City:ROBBINSDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55422-1455
Mailing Address - Country:US
Mailing Address - Phone:612-709-9090
Mailing Address - Fax:
Practice Address - Street 1:15290 PENNOCK LN
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-7163
Practice Address - Country:US
Practice Address - Phone:952-431-8583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12989122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist