Provider Demographics
NPI:1487830360
Name:JOHNSON, ANGELA MARIE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:MARIE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 MCMILLAN ST
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-1646
Mailing Address - Country:US
Mailing Address - Phone:507-376-5525
Mailing Address - Fax:507-376-3796
Practice Address - Street 1:1316 MCMILLAN ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1646
Practice Address - Country:US
Practice Address - Phone:507-376-5525
Practice Address - Fax:507-376-3796
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH6499124Q00000X
IA02835124Q00000X
SD927124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist