Provider Demographics
NPI:1477659589
Name:JOHSON, RANDALL DAVID (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DAVID
Last Name:JOHSON
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 1:2355 ARIEL ST N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55104
Mailing Address - Country:US
Mailing Address - Phone:651-770-0428
Mailing Address - Fax:651-770-3362
Practice Address - Street 1:2355 ARIEL ST N
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55104
Practice Address - Country:US
Practice Address - Phone:651-770-0428
Practice Address - Fax:651-770-3362
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist