Provider Demographics
NPI:1578633699
Name:ROBERT J. JOHNSON, D.D.S., P.C.
Entity Type:Organization
Organization Name:ROBERT J. JOHNSON, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:906-884-4040
Mailing Address - Street 1:400 LAKE ST
Mailing Address - Street 2:STE 101
Mailing Address - City:ONTONAGON
Mailing Address - State:MI
Mailing Address - Zip Code:49953-1034
Mailing Address - Country:US
Mailing Address - Phone:906-884-4040
Mailing Address - Fax:906-884-4080
Practice Address - Street 1:400 LAKE ST
Practice Address - Street 2:STE 101
Practice Address - City:ONTONAGON
Practice Address - State:MI
Practice Address - Zip Code:49953-1034
Practice Address - Country:US
Practice Address - Phone:906-884-4040
Practice Address - Fax:906-884-4080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010092421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1704352Medicaid