Provider Demographics
NPI:1639437650
Name:JOHNSON, DANIEL V (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:V
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 1:1275 RIVER VISTA ROW
Mailing Address - Street 2:UNIT 136
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-7463
Mailing Address - Country:US
Mailing Address - Phone:701-238-4306
Mailing Address - Fax:
Practice Address - Street 1:1575 20TH ST NW STE 102
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-2932
Practice Address - Country:US
Practice Address - Phone:507-334-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND130951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice