Provider Demographics
NPI:1659482669
Name:JOHNSON, RANDALL WARREN (DDS)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:WARREN
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 1:304 W LYON ST
Mailing Address - Street 2:PO BOX 448
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1308
Mailing Address - Country:US
Mailing Address - Phone:507-532-2233
Mailing Address - Fax:507-532-2234
Practice Address - Street 1:304 W LYON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1308
Practice Address - Country:US
Practice Address - Phone:507-532-2233
Practice Address - Fax:507-532-2234
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND78161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice