Provider Demographics
NPI:1588678387
Name:JOHNSON, DAVID WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WAYNE
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 1:2800 11TH AVE S
Mailing Address - Street 2:SUITE #24
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59405-5263
Mailing Address - Country:US
Mailing Address - Phone:406-761-1091
Mailing Address - Fax:
Practice Address - Street 1:2800 11TH AVE S
Practice Address - Street 2:SUITE #24
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59405-5263
Practice Address - Country:US
Practice Address - Phone:406-761-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT-14511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice