Provider Demographics
NPI:1629029095
Name:JOHNSON, DALE (OD)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002749152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP31680002OtherMEDICARE PLUS BLUE
MIDJ002749OtherBCBS
MIP31680002OtherMEDICARE PLUS BLUE