Provider Demographics
NPI:1497822985
Name:JOHNSON, MAUREEN ANNE (RDH CDHC)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:ANNE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:RDH CDHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4114 3RD ST NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7564
Mailing Address - Country:US
Mailing Address - Phone:507-252-9776
Mailing Address - Fax:
Practice Address - Street 1:210 WOOD LAKE DR SE
Practice Address - Street 2:SUITE B
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55904-5529
Practice Address - Country:US
Practice Address - Phone:507-424-1040
Practice Address - Fax:507-424-1042
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH3878124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN030993100OtherMA PROVIDER #