Provider Demographics
NPI:1598828899
Name:JOHNSON, RANDALL CRAIG (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:CRAIG
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 1:103 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:BELGRADE
Mailing Address - State:MT
Mailing Address - Zip Code:59714-4419
Mailing Address - Country:US
Mailing Address - Phone:406-388-4064
Mailing Address - Fax:406-388-4065
Practice Address - Street 1:103 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:BELGRADE
Practice Address - State:MT
Practice Address - Zip Code:59714-4419
Practice Address - Country:US
Practice Address - Phone:406-388-4064
Practice Address - Fax:406-388-4065
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1712122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0114400Medicaid
AJ2866676OtherDEA