Provider Demographics
NPI:1568714590
Name:JOHNSON, JOEL MICAH (DDS)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:MICAH
Last Name:JOHNSON
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 1:10211 DUPONT CIRCLE DR W STE A
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1625
Mailing Address - Country:US
Mailing Address - Phone:260-489-8989
Mailing Address - Fax:734-763-8100
Practice Address - Street 1:10211 DUPONT CIRCLE DR W STE A
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1625
Practice Address - Country:US
Practice Address - Phone:260-489-8989
Practice Address - Fax:734-763-8100
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010208241223G0001X
IN12011754A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No1223G0001XDental ProvidersDentistGeneral Practice