Provider Demographics
NPI:1568606283
Name:DR. WARREN JOHNSON, DDS
Entity Type:Organization
Organization Name:DR. WARREN JOHNSON, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-334-5602
Mailing Address - Street 1:422 HERITAGE PLACE
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021
Mailing Address - Country:US
Mailing Address - Phone:507-334-5602
Mailing Address - Fax:507-334-3488
Practice Address - Street 1:422 HERITAGE PLACE
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021
Practice Address - Country:US
Practice Address - Phone:507-334-5602
Practice Address - Fax:507-334-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7748122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN950017100Medicaid