Provider Demographics
NPI:1598893638
Name:JOHNSON, ROSS HARCOURT (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:HARCOURT
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 1:2215 E CLAIREMONT AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701
Mailing Address - Country:US
Mailing Address - Phone:715-835-2332
Mailing Address - Fax:715-835-9924
Practice Address - Street 1:2215 E CLAIREMONT AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701
Practice Address - Country:US
Practice Address - Phone:715-835-2332
Practice Address - Fax:715-835-9924
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1121G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice