Provider Demographics
NPI:1609828870
Name:DALE JOHNSON OD LLC
Entity Type:Organization
Organization Name:DALE JOHNSON OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:906-632-2020
Mailing Address - Street 1:724 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-2410
Mailing Address - Country:US
Mailing Address - Phone:906-632-2020
Mailing Address - Fax:
Practice Address - Street 1:724 CEDAR ST
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-2410
Practice Address - Country:US
Practice Address - Phone:906-632-2020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002749152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WV0400XEye and Vision Services ProvidersOptometristVision TherapyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4578107Medicaid
0P31680OtherMEDICARE PLUS BLUE
900A710230OtherBLUE CROSS BLUE SHIELD
0P31680OtherMEDICARE PLUS BLUE