Provider Demographics
NPI:1639244650
Name:JOHNSRUD, DARREL HOWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARREL
Middle Name:HOWARD
Last Name:JOHNSRUD
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 1:13998 MAPLE KNOLL WAY
Mailing Address - Street 2:#100
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7004
Mailing Address - Country:US
Mailing Address - Phone:763-420-5599
Mailing Address - Fax:763-416-4771
Practice Address - Street 1:13998 MAPLE KNOLL WAY
Practice Address - Street 2:#100
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55369-7004
Practice Address - Country:US
Practice Address - Phone:763-420-5599
Practice Address - Fax:763-416-4771
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND97641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice