Provider Demographics
NPI:1467498485
Name:JOHNSON, NANCIE J (DDS)
Entity Type:Individual
Prefix:DR
First Name:NANCIE
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:NANCIE
Other - Middle Name:J
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18305 MINNETONKA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DEEPHAVEN
Mailing Address - State:MN
Mailing Address - Zip Code:55391
Mailing Address - Country:US
Mailing Address - Phone:952-936-2206
Mailing Address - Fax:952-936-0901
Practice Address - Street 1:18305 MINNETONKA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DEEPHAVEN
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-936-2206
Practice Address - Fax:952-936-0901
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9836122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN9836OtherDENTAL LICENSE
46554JOOtherBCBS INSURANCE CO
4015051OtherMEDICA INSURANCE CO
4015051OtherMEDICA INSURANCE CO